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Interstitial  Gingivitis 


AND 


PYORRHCEA  ALVEOLARIS 


BY 


El'gexk  S.  Talbot,  M.  S.,  D.  D.  S.,  M.  D.,  LL.  D. 


Late  Professor  of  Stomatology,  Woman's  Medical  School,  Northwestern  University 
Late  Lecturer  on  Stomatology,  Rush  Medical  College,  University  of  Chicago;  Fellow 
of  The  Chicago  Academy  of  Medicine;  Fellowship  Member  op  the  New  York  St^^te 
Dental   Society,    1908;    Secretary    of   Section    on  Stomatology   of    the    American 
Medical    Association;     Vice-President    American    ^Medical    Association      1905- 
Member  VII  International  Medical  Congress,  1881,  London;    Honorary  Presi-  ' 
DENT  X  International  Medical  Congress,  1890,  Berlin;   Honorary  President 
Xll    International    Medical    Congress,     1897,    Moscow;     Corresponding 
Member,  Budapest  Royal  Society  of  Physicians;    Honorary  President 
International  Association  of  Stomatology,  1907,  Paris;   Member  First 
French  Congress  of  Stomatology,  1907,  Paris;   Honorary  Secretary 
Pan-American  Medical  Congress,  1901,  Havana;  Honorary  Member 
Odontologischen     Gesellschaft,     Berlin;      Honorary    Member 
Association  Generals  des  Dentistes  de  France.  Paris;  Honor- 
ary   Member    Sociedad    Odontological    Espanola,    INIadrid; 
Corresponding  Member  Dansk-Tandlaegeforening,   1901;' 
Honorary  Member   Stomatology   Society   of  Hungary; 
Corresponding  Member  of  the  Italian  Stomatological 
Federation,     1910;     Member    Chicago    Academy    of 
Sciences;    Member  American  Association  for  the 
Advancement    of    Science;     Charter    Member 
American    Institute    of    Criminal    Law    and 
Criminology;      IMember     of    the    Author's 
Club,  London. 
Author  of  the  following  books:  "The  Irregularities  of  the  Teeth  and  their  Treatment-' 
Chart  of  Typical  Forms  of  Constitutional  Irregularities  of  the  Teeth;"    The 
Etiology    of   Osseous   Deformities    of   the   Head,    Face,    Jaws    and   Teeth;" 
"Degeneracy:     Its    Signs,    Causes    and    Results;"     "Developmental 
Pathology:    A   Study   in   Degenerative  Evolution,"    etc.,    etc. 


WITH  102  ILLUSTRATIONS 


TOLEDO,  O. 
THE  RANSOM  &  RANDOLPH  CO. 

1913 


r  y^..,JU^<^  ni«^'S^'^^.S-»«. 


1^)3 


ENTERED  ACCORDING  TO  ACT  OF  CONGRESS 
IN  THE  YEAR   1913,  BY 

EUGENE  S.  TALBOT 

IN  THE  OFFICE  OF  THE  LIBRARIAN   OF  CONGRESS 
AT  WASHINGTON,  D.  C. 

All  Rights  Reserved 


THE   PUBLISHERS'  PRESS 
CHICAGO 


To 
MISS  ELLA  CLAY 

Aiy  Late  Faithful  Assistant 

Whose  scientific  ability  was  recognized  and  appreciated  by  scientists 

This  work  is  dedicated 


PREFACE. 


In  this  book  the  etiology,  pathology  and  treatment  of  peri- 
dontal  disease  have  been  worked  out  by  actual  research  which 
covered  a  period  of  thirty-five  years.  Up  to  the  present  time 
teachers  and  practitioners  have  taught  that  disease  of  the  gums 
and  alveolar  process  was  of  a  pyorrhceic  or  infectious  nature. 
All  etiologic  experiments  and  treatment  are  made  from  this 
basis.  The  tendency  at  the  present  time  is  to  study  diseases  of 
the  body  from  a  bacteriological  view  point.  It  is  now  known 
that  many  different  tissues  and  organs  of  the  body  undergo 
physiologic  and  chemic  changes  which  are  often  due  to  irrita- 
tions setting  up  inflammation  and  may  later  under  certain  con- 
ditions become  infected  by  bacteria.  Inflammations  of  the 
mucous  membranes  due  to  acid  states  and  burns  are  of  this 
nature.  It  has  been  the  aim  of  the  author  to  classify  the 
inflammations  due  to  infections  and  those  due  to  chemic 
changes  and  local  and  constitutional  irritations.  The  diseases 
of  the  alveolar  process  due  to  infections  are  usually  of  systemic 
origin  and  develop  symptoms  in  other  parts  of  the  body  such  as 
tuberculosis,  typhoid  fever,  anthrax,  actinomycosis,  etc.,  and 
are  rarely  referred  to  the  specialist  for  treatment.  The  pa- 
tients referred  to  the  specialists  are  those  with  inflammations 
of  the  gums,  mucous  membrane  and  alveolar  process  due  to 
irritations  and  which  ma}"  or  may  not  later  become  infected  by 
bacteria. 

The  author  has  observed  that  every  vertebrate  having  two 
sets  of  teeth  during  life  may  possess  an  inflammatory  condition 
of  the  alveolar  process  to  a  greater  or  less  extent  after  the  first 
set  of  teeth  has  developed  depending  upon  environment  and 
the  condition  of  the  system. 

The  pyorrhceic  stage  which  may  develop  later  is  observed 
in  only  a  very  small  per  cent  of  patients.    Happily,  to  a  certain 


11  PREFACE 

extent,  the  profession  has  come  to  realize  the  importance  of  the 
two  periods  and  the  teaching  of  the  pathology  and  bacteriology 
of  the  disease  is  much  simplified  and  better  understood. 

The  great  law  of  medical  science,  that  to  know  the  cause  is 
half  the  treatment,  is  as  applicable  to  diseases  of  the  mouth  as 
to  any  other  specialty  of  medicine,  and  is  as  applicable  to  dental 
problems  as  to  those  of  biology  generally.  Treatment  of  any 
disease  without  knowledge  of  its  pathology  is  practically  a 
failure. 

While  much  has  been  written  upon  the  pyorrhoeic  stage  of 
interstitial  gingivitis  and  its  treatment,  during  the  past  two 
decades,  no  new  principle  has  been  advanced  w^hereby  the  parts 
can  be  restored  to  a  healthy  condition,  or  whereby  the  disease 
can  be  prevented.  The  disease  is  admittedly  on  the  increase. 
This  seems  at  first  sight  to  indicate  that  dental  prophylaxis  and 
treatment,  so  far  as  this  disease  is  concerned,  are  failures. 

Nearly  three  decades  ago  I  felt  and  expressed  the  necessity 
for  more  extended  study  (Dental  Cosmos,  1886,  page  689)  of 
the  clinical  aspects  and  etiology  of  this  disease.  Even  daring 
apparently  diverse  and  separated  studies,  such  as  those  related 
to  dental  and  maxillary  irregularities  and  degeneracy,  the  ne- 
cessity for  this  has  forced  itself  still  further  upon  me.  In  the 
present  study,  the  disease  has,  of  necessity,  been  considered 
from  the  broad  standpoint  of  general  pathology.  In  all  in- 
stances where  possible  personal  elements  of  error  are  present, 
these  have  been  eliminated  by  having  researches  made  by  more 
than  one  observer. 

The  attempt  has  been  made  to  summarize  all  researches  on 
the  subject.  So  much  have  opinions  been  intermingled  that  it  is 
possible  that  proper  credit  for  priority  has  unintentionally  not 
been  given. 

The  author  is  under  obligation  to  the  following  scientists  for 
their  kind  assistance :  Dr.  Ludwig  Hektoen,  Pathologist,  Rush 
Medical  College;  Dr.  Jerome  H.  Salisbury,  Chemist,  Rush 
Medical  College ;  Dr.  W.  A.  Evans,  Pathologist,  Columbus  Med- 
ical Laboratory,  Professor  of  Pathology,  Chicago  College  of 
Physicians  and  Surgeons  and  Milwaukee  Medical  College;  Dr. 
J.  A.  Wesener,  Chemist,  Columbus  Medical  Laboratory,  Profes- 


PREFACE  111 

sor  of  Chemistry,  Chicago  College  of  Physicians  and  Surgeons ; 
Dr.  Vida  A.  Latham,  Pathologist,  Northwestern  Uinversity, 
Woman's  Medical  School;  Dr.  Maximilian  Herzog,  Pathologist, 
Chicago  Polyclinic  Hospital;  Professor  Theo.  A.  Ed^\an  Klebs 
and  Dr.  Robert  F.  Zeit,  Pathologists,  and  Dr.  W.  L.  Baum, 
Professor  of  Diseases  of  the  Skin,  Post-Gradnate  Medical 
School,  Chicago;  Dr.  G.  V.  I.  Brown,  Professor  of  Oral  Sur- 
gery, Dental  Department,  Milwaukee  Medical  College;  Dr. 
Frederick  Noyes,  Histologist,  Dental  Department,  Northwest- 
ern University;  Dr.  J.  G.  Kiernan,  and  to  Blomgren  Bros.  & 
Co.  for  electrotypes,  etc. 

THE  AUTHOR. 
31  North  State  Street,  Chicago. 


CONTENTS 


Chapter 

I. 

II. 

III. 

IV. 

V. 

VI. 

VII. 

VIII. 

IX. 

X. 

XI. 

XII. 

XIII. 

XIV. 

XV. 

XVI. 

XVII. 

XVIII. 

XIX. 

XX. 

XXI. 

XXII. 

XXIII. 

XXIV. 

XXV. 

.     XXVI. 

XXVII. 

XXVIIL 


PAGE. 

History 1 

Introduction    13 

Transitory  Structures :  The  Jaws 19 

Transitory  Structures:  The  Alveolar  Process. .  .  24 
The  Alveolar  Process  Under  the  Microscope.  ...  35 
The  Gums,  Periosteum,  Mucous  and  Peridental 

Membranes  Under  the  Microscope 38 

Inorganic  Salts  and  Interstitial  Gingivitis 73 

Theories  of  Interstitial  Gingivitis 84 

Uric  Acid  and  Interstitial  Gingivitis 87 

Heredity  and  Environment  in  Interstitial  Gingi- 
vitis       95 

Degenerate  Tissues  in  Interstitial  Gingivitis.  .  . .   100 
Bacteriologic  Researches  in  Interstitial  Gingi- 
vitis     104 

Interstitial  Gingivitis  . 112 

Researches  on  Animals  in  Interstitial  Gingivitis .  125 
Researches  on  Human  in  Interstitial  Gingivitis.   156 

Researches  on  Human  in  Pericementitis 175 

Local  Causes  of  Interstitial  Gingivitis 182 

Constitutional  Causes  of  Interstitial  Gingivitis.  194 
Climatic  Influences  in  Interstitial  Gingivitis ....   211 

Scurvy  in  Interstitial  Gingivitis 218 

Toxins  Producing  Trophic  Changes 223 

Autointoxication  in  Interstitial   Gingivitis 235 

Urinary  Signs  of  Autointoxication 247 

Arteriosclerosis,    Endarteritis    Obliterans    and 

Nerve  End  Degeneration 261 

Absorption  of  the  Alveolar  Process  and  Calcic 

Deposits  Upon  the  Roots  of  the  Teeth 275 

Pyorrhoea  Alveolaris 285 

Constitutional  Effects  of  Pyorrhoea  Alveolaris.  .   295 

Treatment    310 

Bibliography 330 

Index 335 


INTERSTITIAL   GINGIVITIS 


CHAPTER  I. 


HISTOEY. 


Inflammation  of  the  peridental  membrane  and  alveolar  pro- 
cess is  probably  coeval  with  man.  Some  of  the  skulls  found 
earliest  in  the  cave-dwelling  period  exhibit  evidences  of  its 
presence.  In  some  of  these,  careful  observation  has  shown  de- 
posits encroaching  upon  the  roots  of  the  teeth  and  resultant  ab- 
sorption of  the  alveolar  process. 

In  the  Swiss  lake-dwellings  and  in  the  earlier  Irish  cran- 
noges  of  like  construction  and  situation,  skulls  are  found,  which 
exhibit  deposits  of  tartar,  inflammation  of  the  peridental  mem- 
brane and  absorption  of  the  alveolar  process.  These  skulls  were 
those  of  primitive  races  in  whom  disease  of  the  jaws  and  teeth  is 
supposed  to  be  absent  or  infrequent.  In  the  skulls  of  the  peo- 
ples exhibiting  the  highest  civilization  at  the  earliest  period — 
those  of  the  Accadians  and  Egyptians — similar  inflammatory 
conditions  are  to  be  found.  This,  however,  was  to  have  been 
expected,  to  judge  from  the  dental  directions  left  among  the 
medical  records  of  these  peoples.  The  Greeks,  Syrians,  Arab- 
ians, Dra^ddians  and  Aryans  of  India  and  the  early  Burmese 
all  suffered  from  this  disorder.  In  the  museum  at  Constan- 
tinople are  the  skulls  of  soldiers  who  fought  at  a  battle  328 
B.  C.  One  of  these  skulls  has  the  anterior  alveolar  process 
entirely  absorbed  away.  The  roots  of  the  right  central,  the 
right  lateral  and  the  left  central  incisors  are  exposed. 

Inflannnation  of  the  peridental  membranes  and  alveolar  proc- 
ess, it  A\ill  be  evident,  is,  therefore,  not  a  modern  disease ;  not  a 
disease  confined  either  to  civilized  or  primitive  races,  but  one 
which  attacked  man  early  in  his  evolution.  Like  most  diseases 
it  has  been  chiefly  discussed  and  analyzed  during  the  past  two 
centuries. 


Z  INTERSTITIAL    GINGIVITIS. 

In  1740  H.  A.  Fauchard  ^  (while  recognizing  the  disease  in 
all  its  essential  features  and  describing  its  principal  symptoms) 
advanced  no  theory  as  to  its  origin. 

In  1778  M.  Jourdain  ^  advanced  the  opinion  that  the  disease 
was  of  scorbutic  origin. 

In  1821  L.  Kaecker  ^  discussed  the  disorder  in  an  essay  on 
the  devastations  of  the  gums  and  alveolar  processes. 

In  1822  M.  Joirac*  (in  a  discussion  of  the  disease),  while 
advancing  no  theory  as  to  its  origin,  called  it  '' pyorrhoea  inter- 
alveolo-dentaire. ' ' 

In  1860  Marshall  de  Calve  ^  advanced  the  opinion  that  the 
disorder  was  of  hereditary  origin. 

In  1867  Magitot,  discussing  the  disorder,  advanced  the 
opinion  that  the  gum,  being  in  all  cases  only  attacked  subse- 
quently, is  not  the  original  seat  of  the  lesion.  In  his  opinion 
systemic  disorders  like  gout,  rheumatism,  albuminuria,  diabetes 
and  angemia  had  an  influence. 

BonwilP  during  the  same  year  expressed  the  opinion  that 
the  disorder  was  due  to  thinness  of  the  alveolar  process  between 
the  teeth,  thus  depriving  the  peridental  membrane  and  gum 
tissue  of  proper  support.  The  want  of  proper  articulation  of 
the  teeth  also  exerted  an  influence. 

In  1870  Brown  ascribed  the  disorder  to  serumal  calculus. 

In  1875  John  T.  Riggs,  after  whom  the  disorder  is  frequently 
called,  entitled  it  (in  a  paper  read  before  the  American 
Academy  of  Dental  Surgery)  suppurative  inflammation  of  the 
gums  and  absorption  of  the  gums  and  alveolar  process. 

During  the  same  year  Scheif  "^  of  Vienna  entitled  the  disorder 
periostitis  dentalis.  He  was  of  the  opinion  that  it  originated 
from  external  irritation  through  mechanical,  thermic  and  chemic 
changes.  The  real  origin  of  the  disorder  was,  in  his  opinion, 
very  often  obscure.  He  doubted,  however,  the  influence  of 
rheumatism. 


^Independent  Dental  Journal,  1875. 

*  Philadelphia  Journal  of  Medical  and  Physical  Science,  1821. 
'  International  Dental  Journal,  Vol.  XIII. 

*  Journal  of  the  American  Medical  Association. 

*  Journal  of  the  American  Medical  Association. 
«  Dental  Cosmos,  Vol.  XXIV. 

■  Wiener  Med.  Presse,  Vol.  XVI. 


HISTORY.  6 

In  1876  Sirletti '  (in  a  discussion  of  the  pathology  of  the 
disorder,  which  he  called  alveolo-dental  periostitis)  regarded  it 
as  due  to  constitutional  conditions,  like  rheumatism,  scrofula, 
syphilis,  etc.,  with  local  causes  as  exciting  factors. 

In  1877  Rehwinkle,^  in  a  paper  on  pyorrhoea  alveolaris,  after 
citing  from  Albright  (of  Berlin)  the  claim  that  the  disorder 
was  due  to  uncleanliness,  mercury  and  the  suppression  of  habit- 
ual secretions,  expressed  the  opinion  that  acquired  and  inherited 
constitutional  defect  often  played  an  important  part  as  etiologic 
factors.  He  was  also  of  opinion  that  mercury  exerted  an  influ- 
ence in  its  causation.  Salivary  deposits  were,  in  his  opinion, 
without  influence. 

Clowes  ^^  was  of  opinion  in  1879  that  the  general  cause  was 
lack  of  nutrition  in  the  parts.  The  use  of  wedges  often  excited 
the  disorder. 

C.  J.  Essig,"  in  1880,  expressed  the  opinion  that  its  predis- 
posing causes  were  unknown,  that  it  occurred  as  a  rule  in  healthy 
persons,  and  that  irregular  and  crowded  teeth  acted  as  an  excit- 
ing cause. 

In  another  paper  during  the  same  year  G.  A.  Mills  "  ex- 
pressed the  opinion  that  the  disorder  was  of  systemic  origin. 
Various  mental  and  physical  influences  aided  its  progress,  such 
as  nervous  exhaustion  and  bodily  and  mental  overwork.  In  his 
opinion  it  frequently  occurred  in  children  and  adolescents  from 
eruptive  fevers.  The  deposit  was  only  a  local  manifestation  of 
the  disorder. 

In  1881  N.  S.  Niles  "  expressed  the  opinion  that  constitu- 
tional conditions  were,  as  a  rule,  without  influence,  and  that  local 
irritating  deposits  were  the  cause  in  twenty-five  per  cent  of  the 
cases  coming  under  his  observation.  He  was  of  opinion  also 
that  the  amount  of  lime  salts  taken  into  the  system  in  drinking 
water  exerted  an  influence.  A  calcic  and  phosphatic  diathesis 
had  an  influence  in  the  production  of  the  disorder. 


*  Gazzetta  Medica  di  Roma,  1876. 

» Dental  Cosmos,  Vol.  XIX. 

'"Ibid.,  Vol.  XXT. 

"  Dental  Cosmos.  Vol.  XXI. 

"  Ibid.,  Vol.  XXTTI. 

"Ibid.,  Vol.  XXIV, 


4  INTERSTITIAL    GINGIVITIS. 

In  1881  (when  there  seemed  to  have  been  many  contributions 
to  the  literature  of  the  subject)  Atkinson  "  expressed  the  opinion 
that  nervous  debihty  or  original  defect  in  innervation  exerted  an 
influence  in  the  production  of  the  disorder.  The  deposits  of 
tartar  were  a  secondary  consequence.  In  the  course  of  his  paper 
he  cited  the  opinion  of  Hamilton  CartAvright  that  Riggs's  disease 
commenced  in  an  unhealthy  condition  of  the  gums  with  a  sec- 
ondary deposit  of  tartar. 

In  a  paper  read  before  the  Dental  Section  of  the  Inter- 
national Medical  Congress,  Walker  ^^  claimed  that  the  starting 
point  of  the  disease  was  subacute  inflammation  passing  into  the 
depths  of  the  alveolar  process  adjacent  to  the  inflamed  gum.  In 
the  discussion  of  this  paper,  Archovy  and  Joseph  Izklai,  of 
Buda  Pesth,  ascribed  the  disorder  to  minute  organisms.  Oakley 
Coles  thought  that  systemic  states  were  the  predisposing  factors, 
while  minute  organisms  exerted  an  exciting  influence. 

In  1882,  L.  C.  IngersolP*^  regarded  sanguinary  calculus  as  a 
manifestation  of  the  disorder,  and  distinguished  it  from  salivary 
deposits. 

Malasses  and  Gallippe,  "  in  1884,  expressed  the  opinion  that 
the  disorder  w^as  of  microbic  origin. 

In  1885,  A.  0.  Rawls  ^^  expressed  the  opinion  that  the  causes 
were  environment  with  morbid  factors,  such  as  malaria,  exces- 
sive sodium,  etc.,  chloride  and  mercury. 

In  1886,  Reese  ^^  expressed  the  opinion  that  the  disorder  had 
its  source  in  the  uric  acid  diathesis  resultant  on  abuse  of  alcohol. 

During  the  same  year,  J.  D.  Patterson  -°  expressed  the  opin- 
ion that  the  disorder  was  of  catarrhal  origin.  Later,  in  1886,  J. 
N.  Farrar  "^  regarded  the  disorder  as  a  combined  result  of  sys- 
temic tendencies  and  local  irritants.  There  was  a  peculiar  con- 
dition of  the  system  associated  with  hypersecretion  laden  with 
increased  earthly  deposits. 


"  Dental  Cosmos,  Vol.  XXIV. 

^^Transactions  of  the  International  Medical  Congress,  1881. 

1"  Dental  Cosmos,  Vol.  XXV. 

"  Ibid.,  A^ol.  XXVI. 

"  Ibid.,  Vol.  XXVII.      . 

"  Independent  Practitioner,  Vol.  VI. 

="  Dental  Cosmos,  Vol.  XXI. 

°^  Independent  Practitioner,  Vol.  VII. 


HISTORY.  0 

A.  R.  Starr  later  also  expressed  the  same  opinion.  He,  how- 
ever, was  unable  to  determine  the  local  irritation  factor,  but 
regarded  it  as  the  same  as  that  which  causes  exostosis  of  the 
cementum.    He  had  found  most  cases  in  the  upper  jaws. 

Black  "  designated  the  disorder  phagadenic  pericementitis. 
It  was  a  specific  infection  of  an  inflammatory  character,  having 
its  origin  in  the  gingiva,  and  was  accompanied  with  destruction 
of  the  peridental  membrane  and  alveolar  walls. 

E.  S.  Talbot  -^  during  the  same  year  regarded  the  disorder  as 
a  local  one,  due  to  both  local  and  constitutional  causes.  The 
disorder  began  with  simple  inflammation  of  the  gums,  which 
afterward  became  chronic. 

He  laid  particular  stress  upon  the  anatomy,  physiology  and 
pathology  of  the  parts  involved,  there  being  no  other  struc- 
tures in  the  human  body  like  them,  hence  their  eas}^  suscepti- 
bility to  disease. 

We  may  consider,  then,  as  predisposing  and  exciting  causes 
a  perverted  condition  of  the  secretions,  low  vitality  of  patient  or 
tissues  or  both,  calcic  deposits  and  all  diseases  which  affect  the 
circulation  such  as  drugs  and  auto  intoxication,  and  as  among 
the  local  causes  catarrh,  fistulae,  salivary  calculus,  irritation 
from  foreign  substances,  which  are  included  as  modern  dentis- 
try, such  as  detached  bristles  from  the  tooth  brush,  too  great 
friction  in  brushing,  injudicious  use  of  the  toothpick,  the  use  of 
ligatures  and  regulating  apparatus,  application  of  the  rubber 
dam  and  clamps,  artificial  dentures  and  regulating  plates,  ac- 
cumulation and  decomposition  of  food  under  artificial  dentures, 
and  at  the  necks  of  the  teeth,  drugs  which  over-stimulate  the 
parts,  the  use  of  tobacco,  fillings  extending  beyond  the  cervical 
margins,  digestive  derangements,  contagion  from  unclean  in- 
struments," and  improper  mouth  washes  and  tooth  powders, 
especially  charcoal.  In  a  word,  whatever  irritates  the  gums, 
alveolar  process  and  peridental  membrane  is  likely  to  produce 
the  lesion  under  consideration.  The  devitalization  of  pulps  and 
tlie  filling  of  roots,  which  throw  increased  work  upon  the  mem- 


"  American  System  of  Dentistry. 
=»  Dental  Cosmos,  Vol.  XXVIII. 


b  INTERSTITIAL    GINGIVITIS. 

brane,  are  also  to  be  accounted  as  among  the  factors  responsible 
for  this  pathological  condition. 

Talbot  pointed  out  that  the  disease  is  contagious  so  far 
as-  one  tooth  becomes  infected  from  another  in  the  same  mouth. 

Of  the  status  of  this  disease  at  the  close  of  the  year  1887, 
the  following  analytic  picture  was  drawn  by  W.  X.  Sudduth  '* : 
''Pyorrhoea  alveolaris  is  a  term  applied  to  the  secondary  stages 
of  a  disease  that  has  its  inception  in  a  catarrhal  stomatitis.  Be- 
ing confined,  as  a  rule,  to  the  margin  of  the  gums  surrounding 
the  teeth,  it  might  be  called  a  'gingivitis,'  were  it  not  for  the 
general  catarrhal  tendency  shown  by  the  entire  mucous  mem- 
brane of  the  mouth  and  nasal  passages.  The  intimate  relation 
between  a  general  catarrhal  idiosyncrasy  and  pyorrhoea  alveo- 
laris is  more  than  mere  coincidence."  Its  common  occurrence  in 
persons  who  have  irregular  teeth  has  also  been  often  noted  by 
Dr.  Sudduth,  who  considers  that  this  fact  has,  besides  the  matter 
of  uncleanliness,  a  direct  bearing  upon  its  pathogeny.  It  is  well 
known  that  the  irregularities  of  the  teeth  present  an  indication 
of  a  degenerative  taint,  and  that  persons  in  whom  irregularities 
occur  are  very  prone  to  catarrhal  affections  of  the  respiratory 
organs,  including  the  nasal  passage.  Their  skin  is  usually  very 
susceptible  to  inflammatory  affections.  Another  feature  is  the 
offensive  ordor  of  the  saliva  of  individuals  who  show  this  partic- 
ular tendency  to  catarrhal  affections  even  in  persons  who  take 
most  scrupulous  care  of  the  teeth.  In  the  majority  of  cases, 
pyorrhoea  is  a  stomatitis  in  which  the  local  and  constitutional 
factors  in  the  production  of  the  disease  are  largely  dependent 
upon  hereditary  catarrhal  dyscrasia  for  their  ability  to  engraft 
themselves  upon  the  tissues.  This  position  is  borne  out  by  the 
clinical  experience  of  Patterson,  of  Kansas  City,  Missouri,  who 
reports  thirty-eight  cases  of  well  marked  pyorrhoea  observed 
by  him,  thirty- three  of  which  presented  undoubted  evidence  of 
nasal  catarrhal  conditions ;  two  were  the  result  of  direct  irri- 
tation of  misfitting  partial  plates,  and  the  remaining  three  were 
apparently  caused  l)y  calcific  deposits.  Patterson  remarks  that 
a  close  examination  of  the  history  of  the  above  quoted  cases 


Sajoiis'  Anuiial,  1888,  Vol.  Ill,  page  365. 


HISTORY.  7 

confirms  the  opinion  that  the  disease  is,  as  a  rule,  an  "oral 
catarrh. ' ' 

From  the  foregoing  W.  X.  Sudduth  feels  justified  in  class- 
ing the  disease  as  a  localized  catarrhal  stomatitis  which  may  be 
either  acute  or  chronic.  Acute  catarrhal  inflammation  of  the 
gums  begins  in  circumscribed  points  which  present  a  bright  or 
rose-red  color,  and  which  are  generally  located  on  the  margin 
or  the  rugae  of  the  palate.  There  is  but  little  swelling  because 
of  the  dense  nature  of  the  sub-epithelial  connective  tissues. 
The  gums  present  the  same  stages  as  are  found  in  inflamma- 
tion of  other  mucous  surfaces — first  dryness,  followed  by  an 
increased  secretion  of  mucus.  The  parts  are  very  sensitive  to 
pressure;  the  patient  complains  of  an  annoying,  burning  sen- 
sation. The  appearance  of  the  gums  is  noticeably  smooth  and 
glistening.  They  bleed  easily  when  the  brush  is  used  or  even 
during  a  meal.  This  stage  does  not  last  very  long,  but  soon 
heals  by  resolution  or  passes  into  a  chronic  catarrhal  stomatitis 
in  which  condition  the  gums  become  markedly  swollen  and  tur- 
gid. They  present  a  condition  of  tumefaction  that  sometimes 
rapidly  passes  into  hypertrophy;  at  other  times  there  is  an 
indurated  appearance  that  may  last  for  some  time.  Granula- 
tion tissue  may  be  produced  as  the  result  of  overstimulation. 
The  gums  become  detached  from  the  necks  of  the  teeth;  and 
pockets  are  formed  from  which  a  fetid  discharge  may  be 
pressed,  giving  a  peculiarly  disagreeable  odor.  Bullae  are  apt 
to  form,  which,  by  rupturing  in  the  process  of  mastication, 
give  rise  to  intense  smarting.  The  tongue  constantly  seeks  the 
surface  if  the  bull»  are  on  the  inner  side. 

The  pathologic  changes  which  take  place  are,  according  to 
Newland  Pedley,  of  England,  "hypertrophy  of  the  muco-peri- 
osteal  fold  around  the  teeth,  accompanied  by  dilatation  of  capil- 
lary loops,  enlargement  of  the  papillae  and  rapid  proliferation  of 
epithelial  cells.  Later  the  gums  become  firm  and  contracted  and 
display  increase  of  fibrous  tissue.  The  changes  which  go  on  in 
the  socket  have  not  been  as  yet  satisfactorily  worked  out.  The 
examination  of  the  jaws  of  carnivora,  apparently  affected  mth 
pyorrhoea  alveolaris,  leads  to  the  supposition  that  osteitis  of  the 
alveolar  process -spreading  toward  the  apex  of  the  socket  is  pres- 


8  INTERSTITIAL    GINGIVITIS. 

ent.  Later  tlie  alveolar  walls  become  absorbed  and  are  at  times 
more  or  less  denuded,  while  the  fangs  of  the  teeth  become  coated 
with  a  layer  of  thin,  hard,  green-brown  tartar.  Ultimatel}^  the 
disease  progressing,  the  teeth,  one  after  another,  drop  out." 

From  what  has  been  said  it  will  be  seen  that  the  pathology 
of  pyorrhoea  alveolaris  may  be  explained  in  several  ways.  The 
general  causes  are  local  or  symptomatic,  or  both  combined.  The 
most  common  cause  of  catarrhal  gingivitis  is  found  in  local 
irritation,  combined  with  some  hereditary  disposition  to  catar- 
rhal affections.  The  next  greatest  etiologic  factor  is  sympto- 
matic— the  local  manifestation  of  a  constitutional  vice.  The 
most  common  manifestation  is  that  of  syphilis  and  of  its  anti- 
dotes, mercury  and  potassium  iodide,  both  of  which  sometimes 
find  expression  in  a  localized  inflammation  which  may  be  the 
starting  point  for  pj^orrhoea  alveolaris.  As  a  complication  of 
the  disease  in  its  secondary  stages  there  can  be  no  doubt  of  the 
action  of  micro-organisms,  but  Sudduth  does  not  feel  justified 
in  conceding  to  them  a  position  of  specificity. 

His  position  above  quoted  is  sustained  by  Pedley,  who  finds 
that  in  most  instances  it  is  due  to  some  constitutional  condition. 
The  fact  that  it  is  often  symmetrical  and  frequently  hereditary 
gives  support  as  to  this  view.  It  occurs  in  mouths  of  patients 
whose  health  has  been  undermined  by  debilitating  influences  and 
injudicious  habits  of  living.  It  is  a  common  sequel  of  malarial 
fever.  Young  persons  recovering  from  eruptive  fevers  are  some- 
times subjects  of  pyorrhoea  alveolaris.  Frequent  pregnancies 
are  a  fruitful  source  of  the  disorder.  Attention  has  been  lately 
drawn  to  the  shedding  of  the  teeth  in  tabes  dorsalis,  but  it  does 
not,  however,  seem  to  be  a  constant  symptom.  Pedley 's  view, 
although  tending  entirely  toward  the  constitutional  character  of 
the  disease,  does  not  militate  against  its  catarrhal  nature. 

Bland  Sutton  has  found  shedding  of  teeth  frequent  in  rheu- 
matoid arthritis  in  animals.  He  has  also  met  \vith  it  in  mollities 
ossium  and  other  wasting  diseases.  Magitot  (who  views  the 
alveolar  dental  periosteum  as  a  ligament  and  not  of  the  same 
nature  as  osseous  periosteum)  calls  the  disease  symptomatic 
alveolar-arthritis,  and  mentions  especially  as  causes,  chronic 


HISTORY. 


Bright 's  disease  and  glycosuria,  in  which  latter  condition  the 
phenomenon  is  absolutely  constant. 

Patterson  holds  that  "mouth-breathing  has,  in  his  expe- 
rience, been  a  very  common  accompanying  condition  which  he 
cannot  help  connecting  with  the  production  of  the  disease.  By 
it  the  gums  are  kept  dry,  their  functions  destroyed  and  the  way 
paved  for  catarrhal  inflammation.  The  majority  of  the  patients 
he  has  been  called  upon  to  treat  have  been  otherwise  healthy, 
robust  persons.  From  this  fact  he  does  not  favor  the  idea  of  the 
disease  being  dependent  upon  constitutional  derangement.  It 
is,  however,  a  Avell-known  fact  that  these  are  the  very  class  of 
people  who  when  irritation  is  once  set  up  in  their  system,  present 
the  most  aggravated  cases,  by  reason  of  their  superfluous  vital- 
ity. He  says  he  has  occasionally  met  with  cases  where  the  local 
condition  w^as  evidently  aggravated  by  constitutional  derange- 
ment and  cure  w^as  thereby  retarded.  The  great  majority  of 
cases,  however,  have  shown  no  indication  of  constitutional  pre- 
disposition, but  have  pointed  unerringly  to  local  irritation  by 
means  of  which  the  function  of  the  mucous  membrane  had  been 
destroyed." 

Syphilis  and  other  aifections  may  engraft  themselves  upon 
the  gums  without  a  predisposition  of  the  parts  toward  an  inflam- 
matory condition,  and  having  disturbed  the  normal  status  of  the 
gingival  margins  they  pave  the  way  for  subsequent  disease  in 
the  alveolus.  Certain  drugs,  such  as  mercury,  phosphorus,  lead, 
etc.,  have  a  known  deleterious  action  upon  the  ligamentous  at- 
tachment of  the  teeth. 

In  1890  Miller  ^"  expressed  the  opinion  that  the  disorder  was 
of  a  parasitic  nature. 

In  1892  C.  N.  Pierce ''  charged  the  disorder  chiefly  to  sys- 
temic predisposition  and  enthusiastically  advocated  the  theory 
of  Reese  as  to  the  influence  of  the  uric  acid  diathesis. 

In  1894  W.  X.  Sudduth"  strongly  urged  the  influence  of 
lactic  acid  as  a  local  factor  in  the  disorder. 

M.  L.  Rhein  ^^  presented  a  method  of  classifying  pyorrhoea 


-^  ^Micro-Organisms  of  the  Human  Mouth. 

-"  Internationa]  Dental  Association,  August,  1894. 

-'  Ibid.,  Vol.  Xiy. 

"^  The  American'Dental  Association,  August,  1894. 


10  INTERSTITIAL    (ilNGIVITIS. 

alveolaris  in  the  following  manner:  "This  classification  is 
made  by  prefixing  to  pyorrhoea  an  adjective  stating  the  name  of 
the  disease  which  is  causing  the  pathological  symptoms  in  the 
oral  cavity  as  'gouty  pyorrhoea,'  'diabetic  pyorrlia'a,'  etc." 

The  author,-^  after  further  researches,  makes  the  positive 
statement  that  the  etiology  of  the  disease  is  due  to  both  consti- 
tutional and  local  causes.  He  again  reiterates  and  makes  the 
positive  statement  that  modern  dentistry  is  producing  more 
''pyorrhoea"  (interstitial  gingivitis)  than  any  other  one  cause. 

He  again  lays  stress  on  the  anatomy  and  physiology  of  the 
parts  involved  and  that  the  alveolar  process  is  a  transient  bony 
structure,  simply  for  the  purpose  of  holding  the  teeth  in  place 
after  they  have  erupted;  that  the  gums  are  rarely  found  in  a 
healthy  condition ;  that  the  peridental  membrane  is  never  in- 
vaded by  pus  germs  so  long  as  it  is  in  a  perfectly  normal  state ; 
that  in  phthisical  patients  and  those  with  low  vitality  and  pa- 
tients who  have  been  ill  for  any  length  of  time,  a  low  form  of 
inflammation  of  the  gums  extending  to  the  peridental  membrane 
and  alveolar  process  with  pus  infection  takes  place;  that  the 
granular  debris  or  calcic  deposits  in  all  cases  are  secondary  con- 
siderations in  the  breaking  down  of  tissue. 

Neurotics  and  degenerates,  whether  wealthy  persons  or  those 
confined  in  institutions,  are  mostly  afflicted.  Children  as  well  as 
grown  people  suffer  with  the  disease. 

In  1897  the  author  laid  particular  stress  on  the  poisons  cir- 
culating in  the  blood  causing  interstitial  gingivitis  from  auto- 
intoxication. 

In  1899  he  ^°  he  spoke  of  the  possibility  of  calcic  deposits  on 
the  roots  of  the  teeth  being  "calcareous  matter  absorbed  from 
the  alveolar  process  in  the  immediate  vicinity  of  the  root,"  etc. 
This  theory  was  later  confirmed  by  researches  on  the  alveolar 
process  and  mentioned  in  a  paper  on  "Interstitial  Gingivitis," 
published  in  The  Dental  Summary,  1903. 

John  Fitzgerald,'^  in  1899,  claimed  that  "The  production  of 
pyorrhoea  depends  upon  two  factors,  a  predisposing  cause  and 


'^  The  International  Dental  .Tonrnal,  April,  1896. 

^°  Interstitial  Gingivitis  or  So-called  Pyorrhoea  Alveolaris,  page  169. 

*^  Clinical  Journal,  March  1,  1899. 


HISTOEY.  11 

a  local  irritation.  The  predisposing  cause  may  be  tuberculosis, 
syphilis,  scurvy,  the  exhaustion  of  acute  infectious  diseases  or 
any  other  source  of  malnutrition.  The  exciting  cause  may  be, 
and  most  usually  is,  a  gingivitis  produced  in  one  of  the  ways  to 
be  presently  described.  There  is  also  a  pyorrhoea  of  gouty 
origin,  in  which  the  local  necrosis  of  the  peridental  membrane  is 
caused  by  gouty  disease  of  one  of  the  blood  vessels  in  its  sub- 
stance." 

The  views  on  etiology  of  this  condition  have  varied,  it  will 
be  observed,  from  purely  constitutional  causes  to  purely  local 
causes,  inclusive  of  microbic  affections.  In  the  main  it  will 
be  ob\T-ous,  however,  that  both  constitutional  causes,  whether 
inherited  or  acquired,  have  been  regarded  as  of  influence  by  the 
majority  of  those  who  have  written  on  the  subject.  There  has, 
however,  been  very  little  exact  study  of  either  the  predisposing 
or  the  exciting  causes  of  the  condition.  Even  the  impetus  given 
the  study  of  etiology  by  bacteriology  and  embryology  has  as  yet 
failed  to  make  itself  felt  to  any  considerable  degree  in  this 
department  of  dental  pathology. 

In  1903  the  author  spoke  of  the  alveolar  process  as  being  an 
end  organ ;  he  also  laid  stress  upon  inflammation  of  the  alveolar 
process  as  one  of  the  first  diagnostic  symptoms  in  constitutional 
diseases  in  the  same  year. 

In  1904  he  spoke  of  the  pulp  as  being  one  of  the  most  per- 
fect end  organs  in  the  body. 

In  an  article,  '^  Endarteritis  Obliterans  and  Arterial  Hyper- 
trophy in  the  Alveolar  Process,"  ^-  the  author  first  called  atten- 
tion to  the  calcic  deposits  (not  tartar)  on  the  roots  of  the  teeth 
and  stated  that  it  was  "the  detritus  from  the  alveolar  process." 
In  this  article,  he  lays  emphasis  on  the  fact  that  the  alveolar 
process  is  not  only  a  transitory  structure  but  is  also  an  end 
organ  which  makes  it  very  susceptible  to  disease.  The  nerves 
and  blood  vessels  approach  a  blank  Avail.  The  roots  of  the  teeth, 
so  far  as  disease  is  concerned,  are  foreign  bodies. 

Examination  of  the  alveolar  process  of  animals  or  human 
suffering  from  disease,  in  which  the  eliminating  organs  do  not 


The  Dental  Digest,  October,  1903. 


12  INTERSTITIAL    GINGIVITIS. 

throw  off  the  effete  matter  (autointoxication),  especially  in 
syphilitic,  tuberculous  and  scorbutic  persons,  easily  reveals  this 
morbid  state. 

In  "Pathology  of  Root  Absorption  and  Alveolar  Abscess"  ^^ 
absorption  of  the  alveolar  process  is  always  resultant  upon  irri- 
tation and  inflammation.  The  strong  point  is  emphasized  that 
the  alveolar  process  is  doubly  transitory  and  also  an  end  organ. 
He  also  lays  stress  on  the  fact  that  in  the  constructive  stage  of 
the  alveolar  process,  at  the  third  and  fourth  periods  of  stress, 
the  bone  ^\ill  reproduce  itself  but  after  the  person  has  obtained 
his  growth,  very  little  or  no  restoration  can  take  place.  He  also 
states  that  neuroses  or  degeneracy  in  the  child  has  much  to  do 
with  the  success  of  treatment  and  that  autointoxication  also 
plays  a  great  part  in  final  results. 

In  a  paper  on  "Peridental  Abscess,"  ^*  in  some  of  the  lower 
vertebrates,  there  is  a  continuous  succession  of  teeth  called 
polyphyodontia.  When  one  tooth  has  performed  its  function 
it  disappears  to  give  way  to  another.  This  continues  through- 
out life.  In  all  vertebrates,  including  man,  where  only  two  sets 
of  teeth  are  developed,  it  is  called  dyphodontia.  The  alveolar 
process  and  teeth  of  these  vertebrates,  including  man,  have  re- 
tained phylogenetic  remnants  of  the  physiologic  processes  of 
removing  transitory  structures.  Should  man  live  long  enough, 
he  would  normally  lose  his  second  set  of  teeth  by  osteomalacia 
or  juvenile  or  senile  absorption  depending  on  the  age  of  the 
patient.  This  is  a  great  factor  in  the  transitory  nature  of  the 
alveolar  process. 

The  author  first  mentioned  autointoxication  in  an  article, 
"Autointoxication  in  Its  Medical  and  Surgical  Relations  to  the 
Jaws  and  Teeth. "  ^^ 


3"  The  Dental  Digest,  1904. 

"^  The  Dental  Digest,  June,  1903. 

"^  Journal  of  the  American  Medical  Association,  1897. 


CHAPTER  11. 

INTEODUCTIOISr. 

The  attempt  has  been  made  in  the  present  work  to  reduce  to 
order  the  chaotic  notions  as  to  etiology,  pathology  and  treatment 
which,  during  the  present  century,  have  gathered  around  the 
morbid  condition  erroneously  entitled  Pyorrhoea  Alveolaris. 
While  even  erroneous  titles  may  have  their  meaning  so  fixed  by 
usage  that  any  danger  from  the  error  involved  in  the  title  may 
be  practically  nil,  still  this  is  not  the  case  with  the  title  just 
cited.  It  suggests  erroneous  etiology,  since  pyorrhoea  implies 
that  there  must  always  be  a  flow  of  pus,  and  hence  that  the  dis- 
ease must  always  result  from  infection  with  pus  microbes.  It 
implies  erroneous  pathology  and  erroneous  treatment  for  the 
same  reason.  This  being  the  case,  such  a  title  is  so  dangerously 
misleading  as  to  compel  in  the  present  stage  of  dental  science  its 
modified  use  as  a  term  for  a  disease.  With  a  view  of  clearing  up 
this  question  at  the  outset  by  the  use  of  a  proper  title,  I  have 
adopted  as  a  designation  for  the  condition  hitherto  known  as 
pyorrhoea  alveolaris,  the  term  "Interstitial  Gingivitis."  To  this 
designation  (as  to  all  other  attempts  to  express  within  a  small 
space  an  extended  pathology,  etiology,  prognosis,  and  clinical 
aspects)  there  are  some  objections.  The  term  interstitial  is 
used  by  some  pathologists  in  a  limited  obscure  sense.  By  the 
mass  of  dental  pathologists,  surgeons,  physicians,  and  by  med- 
ical lexicographers,  the  term  is  employed  in  precisely  the  sense 
in  which  it  is  used  in  the  present  work.  The  English  surgeon 
and  lexicographer  Quain  defines  interstitial  as  follows :  "Inter- 
stitial (inter,  between;  and  sto,  I  stand) ;  relating  to  the  inter- 
stices of  an  organ.  The  term  is  applied  in  physiology  to  the 
tissue  which  exists  between  the  proper  elements  of  any 
structure,  namely,  some  form  of  connective  tissue.  In 
pathology  the  word  is  used  in  connection  with  absorption 
when  a  part  is  gradually  removed  without  any  obvious 
breaking  off,  and  also  to  indicate  the  implication  of  the  intersti- 
tial tissues  in  morbid  processes  or  their  infiltration  with  morbid 
products,  as  interstitial  pneumonia,  interstitial  hepatitis." 


14  INTERSTITIAL    GINGIVITIS. 

The  Encyclopaedic  Medical  Dictionary  of  the  American 
Foster,  states  that  interstitial  has  three  signitications :  First,  it 
is  applied  to  a  condition  disseminated  through  the  substance  of 
an  organ  or  part,  and  to  an  inflammation  affecting  the  connec- 
tive tissue  of  an  organ;  second,  it  is  also  applied  to  that  form  of 
growth  which  consists  in  the  interposition  of  new  elements  be- 
tween old  ones,  instead  of  in  addition  to  the  surfaces ;  third,  it 
is  applied  to  pathologic  processes  occupying  the  space  between 
the  essential  parts  of  an  organ  which  constitute  its  proper  tissue, 
and  is  then  employed  in  a  sense  opposed  to  that  of  parenchy- 
matous. 

A  glance  at  the  illustrations  demonstrates  the  validity  of  the 
application  of  the  term  interstitial  (in  the  sense  of  Quain,  Fos- 
ter, and  the  other  lexicographers)  to  the  condition  erroneously 
called  pyorrhoea  alveolaris. 

I  have  adopted  the  term  gingivitis  for  reasons  which  will  be 
obvious  at  the  first  glance.  The  philologic  objection  may  be 
made  that  in  it  Greek  and  Latin  are  yoked  together.  Practically 
this  is  no  objection,  since  German,  French,  as  well  as  English, 
medical  authorities  employ  such  terms  of  mixed  origin.  Indeed 
the  French  (Mailhol  ^  for  example)  apply  the  term  gingivitis  to 
the  very  condition  to  which  I  have  applied  it.  In  addition,  they 
add  to  it  the  specific  term  ''expulsive,"  to  designate  "a  form  of 
recession  of  the  gums,  accompanied  by  alveolar  osteoperiostitis, 
and  the  gradual  expulsion  of  the  tooth  from  its  socket."  Fos- 
ter ^  suggests  the  substitution  of  the  term  ulitis  as  more  philo- 
logically  correct.  The  term  gingivitis,  however,  has  crept  into 
such  wide  use,  that  it  would  be  futile  to  attempt  to  displace  it 
for  merely  philologic  reasons. 

The  term  ''gingivitis,"  however,  conveys  the  idea  that  the 
disease  always  begins  at  the  margin  and  is  confined  to  the  gums 
themselves.  Here  again  we  have  an  erroneous  conception  of 
the  pathology  of  the  disease.  Thus  in  the  formation  of  an 
alveolar  or  peridental  abscess,  there  is  an  inflammation  pre- 
ceding the  pyorrhoeic  stage.  This  is  an  interstitial  inflamma- 
tion and  the  gum  tissue  is  not  involved.     Again,  in  inflamma- 


*  Odontalgie. 
"  Foster,  op.  cit. 


INTRODUCTIOJv^.  •  15 

tion  due  to  mercury,  lead,  copper,  brass,  drug,  autointoxications 
and  other  poisonings  and  irritations,  there  is  an  interstitial  in- 
flammation of  the  alveolar  process  and  again  the  gums  are  not 
involved  until  the  disease  proceeds  to  a  later  stage. 

My  researches  have  shown  that  inflammation  may  take  place 
from  irritants  or  poisons  circulating  in  the  blood  at  any  locality 
between  the  gum  margin  "and  the  apical  end  of  the  root  of  the 
tooth.  This  inflammation  may  terminate  in  healthy  resolution  or 
it  may  go  on  to  abscess  with  a  discharge  through  a  small  fistula 
upon  the  gum  which  afterwards  may  heal  without  pain  to  the 
patient  and  the  gingival  margin  may  not  be  involved. 

I  have  shown  microscopic  slides  with  these  pathologic  condi- 
tions in  almost  every  constitutional  disease.  An  inflammation 
may  take  place  at  the  end  of  the  root  due  to  irritation  or  death 
of  the  pulp.  The  gingival  border  is  again  not  involved.  Irrita- 
tion with  inflammation  around  the  roots  of  teeth  occur  in  gout, 
rheumatism,  syphilis  and  many  other  constitutional  diseases 
and  the  gum  margin  does  not  become  diseased  or  the  seat  of  the 
inflammation  may  be  at  any  point  on  the  root  and  extend  to  the 
gingival  border. 

In  all  these  illustrations  the  parts  are  restored  to  health 
without  pyorrhoea  alveolaris  or  even  in  many  cases  gingivitis. 
It  is  in  such  pathologic  conditions  that  the  word  ^'interstitial" 
is  added  to  "gingivitis."  By  this  term,  then,  we  know  just 
what  is  meant.  In  no  other  term  now  in  use  can  we  locate  the 
inflammatory  area. 

The  two  terms  I  have  employed  convey  a  fairly  correct  idea 
of  the  pathologic  process  involved  in  both  deep-seated  and  super- 
ficial inflammation,  and  do  not  imply  erroneous  views  as  to 
etiology,  pathology,  prognosis  and  treatment. 

The  pathologic  conception  adopted  in  the  present  work  anent 
interstitial  gingivitis  is  that  the  disorder  is  a  local  inflammatory 
condition  of  the  gums,  or  alveolar  process,  or  both,  tending  to 
accelerate  their  normal  tendency  to  disappearance  at  certain 
periods  of  stress,  or  involution,  of  which  involution  the  changes 
produced  by  old  age  are  a  type.  In  this  early  senility  of  the 
gums  and  alveolar  process,  for  such  it  may  be  termed,  two 
great  types  of  causes  play  a  part;  the  exciting  and  the  pre- 


16  INTERSTITIAL    GINGIVITIS. 

disposing  causes.  The  exciting  causes  may  be  purely  local,  or 
may  be  local  expressions  of  constitutional  states.  Thus  it  will 
be  shown  that  the  influence  of  uric  acid  when  present  is  exerted 
as  a  local  irritant,  and  not  as  a  constitutional  factor — the  theory 
urged  so  strongly  by  Pierce.  The  uric  acid  hypothesis,  once 
very  dominant  in  medicine,  is  now  losing  its  force.  The  trend 
of  medical  opinion  is  to  consider  it  one  of  the  danger  signals  of 
autointoxication  which  assumes  prominence  because  of  its  ten- 
dency to  excite  local  irritation.  It  is  but  one  of  a  number  of 
local  expressions  of  constitutional  defect.  This  view  of  the  in- 
fluence of  uric  acid  in  etiology  the  present  work  will  try  to  dem- 
onstrate. Prominent  among  etiologic  factors  which  have  to  be 
reckoned  with,  are  pathogenic  germs.  In  the  present  work  it  will 
be  shown  by  all  laws  of  bacteriology  (under  which  investiga- 
tions must  be  conducted)  that  there  is  no  specific  germ  which 
is  capable  of  producing  the  disease  itself,  and  furthermore,  that 
the  pyorrhoea  stage  of  the  disease  is  merely  a  complication  due 
to  pyogenic  germ  infection  of  the  already  diseased  gums.  The 
views  of  Galippe  as  to  a  specific  organism  will  be  shown  to  have 
failed  of  support  by  numerous  control  experiments  described  in 
the  present  work.  As  these  have  been  conducted  by  different 
experimenters  they  are  free  from  the  personal  elements  of  error 
which  vitiate  the  researches  of  Galippe,  who  violated  that  canon 
of  the  laws  of  Koch  which  compels  production  of  the  disease  by 
the  alleged  specific  germ.  One  predisposing  factor  will  be 
shown  in  the  present  work  to  be  the  nature  of  the  structures 
affected.  This  in  pathology  is  called  local  predisposition.  The 
gums,  alveolar  process,  etc.,  will  be  shown  to  be  transitory 
structures,  as  well  as  end  organs,  in  themselves  predestined  (as 
already  stated)  to  certain  changes  at  certain  ages.  By  the  in- 
fluence of  the  disease,  about  to  be  discussed,  these  changes 
occur  prematurely.  The  influence  of  the  toxic  agents  (mercury, 
potassium  iodide,  etc.)  will  be  shown  to  have  been  exerted  con- 
stitutionally through  the  central  nervous  system,  their  local  ef- 
fects being  a  secondary  consequence  of  this.  The  same  will  be 
shown  to  be  the  case  with  conditions  like  scurvy  and  autointoxi- 
cation (where  the  constitutional  factor  is  most  prominent),  and 
with  the  great  neuroses   (paretic  dementia,  locomotor  ataxi<'t, 


IXTRODUCTIOX.  17 

etc.)-  Here,  as  in  the  toxic  conditions,  one  great  element  consid- 
ered is  the  influence  of  the  constitutional  conditions  upon  the 
nerves  governing  local  blood  supply  and  tissue  waste  and  repair. 
These  influences  are  significantly  illustrated  in  the  various  proc- 
esses described  later  which  tear  down  and  build  up. 

The  influence  of  morbid  heredity  as  a  direct  factor  ^\dll  be 
shown  not  to  be  great.  The  influence,  however,  of  degeneracy 
expressing  itself  along  the  lines  of  least  resistance  ^\ill  appear 
as  an  ominously  important  factor.  Heredity  here,  as  elsewhere, 
is  a  warning  rather  than  a  destiny. 

The  influence  of  the  nervous  system  on  the  processes  of 
growth  and  repair,  which  is  called  its  trophic  function,  has  been 
shown  to  play  a  part  in  both  the  etiology  of  the  disease  and  in 
its  progress.  This  function  has  received  but  little  attention  from 
dentists,  albeit  its  influence  has  been  recognized  in  dental  path- 
ology in  connection  A\ith  great  neuroses  like  paretic  dementia 
and  locomotor  ataxia,  in  which  gum  disorders  occur,  followed  by 
loosening  of  the  teeth.  The  pathology  of  the  disease  has  been 
discussed  in  the  light  of  established  facts  of  general  pathology 
which  have  been  accepted  by  the  leading  dental  investigators, 
and  not  merely  from  a  hypothetic  standpoint.  The  disease  has 
been  regarded  as  a  local  exaggeration  of  certain  physiologic 
processes,  accompanied  by  diminution  of  the  intensity  of  others. 
In  the  study  of  this  phase  of  the  question,  the  latest  researches 
of  dental  pathologists  as  well  as  original  observation  and  ex- 
periment have  been  employed. 

Among  tbe  many  questions  which  the  present  treatise  is 
believed  to  settle  (so  far  as  experimentation  can)  is  the  follow- 
ing: The  question  of  the  influence  and  nature  of  its  etiology. 
It  is  shown  that  here,  as  elsewhere  in  biology,  the  etiology  of 
morbid  conditions  has  many  phases ;  that  in  it  exciting  and  pre- 
disposing causes  have  alike  to  be  considered ;  that  while  causes 
may  be  constitutional  in  origin  they  very  often  exert  their 
action  locally;  that  the  disease  is  not  a  product  of  civilization 
nor  a  product  of  any  one  etiologic  factor ;  that  there  is  no  ground 
yet  adduced  for  believing  the  disease  to  be  specifically  infectious 
and  due  to  a  germ  of  a  specific  nature ;  that  in  it  the  germ  infec- 
tion occurs  as  a  consequence  of  existing  disease,  and  is  not  the 


18  INTERSTITIAL    GINGIVITIS. 

cause  of  the  morbid  condition,  but  one  of  its  stages  :  Pyorrhoea. 
The  experiments  made,  as  well  as  the  pathologic  and  chnical 
data,  have  been  obtained  from  many  observers,  so  that  as  many 
control  observations  should  be  had  as  were  necessary  to  elim- 
inate personal  elements  of  error  inevitable  upon  original  obser- 
vation and  research.  In  the  pathology  no  statement  is  made 
which  is  not  demonstrated  by  corroboratory  data,  including  a 
photograph  of  the  condition.  The  treatment  has  been  based  upon 
the  pathology  and  etiology.  Its  central  idea  is  that  the  human 
being  must  be  regarded  as  something  more  than  his  mouth  and 
teeth;  hence  the  duty  of  the  dental  scientist  is,  like  that  of  all 
medical  scientists,  best  shown  in  a  prophylactic  direction. 


CHAPTER  III. 

TRANSITORY   STRUCTURES. 
THE  JAWS. 

Because  of  man's  advance  in  evolution  and  because  of  the 
local  degeneracies  tliereon  resultant,  through  the  law  of  economy 
of  growth  whereby  one  structure  is  sacrificed  for  the  benefit  of 
the  organism  as  a  whole,  the  face,  jaws,  teeth,  gums,  alveolar 
process  and  peridental  membrane,  being  variable  structures,  are 
predisposed  to  disease  in  their  very  order  of  evolution. 

The  jaws  are  growing  smaller  because  large  ones  are  not 
required.  The  structures  are  changing  their  shapes  to  adapt 
themselves  to  the  new  environment.  Thus — instead  of  broad 
large  jaws  with  low  vaults ;  short,  broad  alveolar  processes  with 
plenty  of  blood  supply  and  vitality  to  resist  mastication;  teeth 
short,  ^vith  large  bell  crowns  to  give  plenty  of  room  between  the 
roots  for  considerable  thickness  of  the  alveolar  process  for  the 
nourishment  of  the  peridental  membrane  and  support  and  pro- 
tection of  the  gum  tissue — small  narrow  jaws  occur  ^yith  appar- 
enth"  high  vaults;  long,  slender  and  thin  alveolar  processes, 
which  are  not  used  in  mastication  with  sufficient  force  to  carry 
the  blood  for  the  nourishment  of  the  tissues.  The  teeth  are 
changing  their  shape,  causing  the  roots  to  come  closer  together, 
and  thus  lessening  the  area  of  the  alveolar  process. 

That  the  jaws  of  man  are  growing  smaller  is  easily  demon- 
strated. Scientists  claim  two  types  of  heads  as  a  starting  point 
in  the  study  of  head  and  face  deviations,  the  brachycephalic 
(round)  head  of  the  Teutonic  race  and  the  dolichocephalic 
(long,  narrow)  head  of  the  negro.  These  two  primitive  types 
of  heads  possess  two  distinct  types  of  jaws.  The  brachycephalic 
head  has  a  large  round  dental  arch;  the  jaws  and  dental  arches 
may  or  may  not  protrude,  while  the  dolichocephalic  head  has 
large,  long,  protruding  jaws  and  dental  arches.  The  normal  nat- 
ural tendency  in  the  evolution  of  man  is  to  eventually  (owing  to 


20 


INTERSTITIAL   GINGIVITIS. 


admixture  of  races  and  environment)  harmonize  these  two  types 
and  produce  a  mesaticephalic  (medium)  head,  face  and  jaws. 
The  frontal  development  of  the  brain  in  phylogeny  is  gradually 
causing  the  skull  bones  to  project  forward.  Owing  to  disuse  in 
ontogeny  the  jaws  are  growing  smaller  and  receding. 

While  these  changes  are  gradually  going  on  normally,  cer- 
tain factors  are  brought  to  bear  upon  the  mother  and  child  which 
increase  or  diminish  the  nutrition  of  the  child  and  bring  about 
arrest  or  excessive  development  of  the  face,  jaws  and  teeth. 
These  factors  are  an  unstable  nervous  system  ^  either  in  parent 
or  child  or  both. 


Fig.  1. — Illustrates  thk  Primitive  Head  with  a  Eeceding  Forehead  and  Protrud- 
ing Face  and  Jaw.  The  Second  Illustration  Shows  an  Advance  in  Evolu- 
tion WITH  the  Head,  Face  and  Jaavs  on  a  Perpendicular  Line,  While  the 
Third  Shows  a  Recession  of  the  Face  and  Jaws. 

That  these  views  can  be  verified  are  easy  of  demonstration. 
Drop  a  perpendicular  line  (Fig.  1)  from  the  supraorbital  ridge 
below  the  lower  jaw.  It  will  be  found  that  in  most  of  the  prim- 
itive races  the  jaws  will  protrude  outside  the  line  and  the  fore- 
head will  remain  inside  the  line.  As  a  human  face  has  advanced 
in  its  phylogeny,  the  reverse  has  taken  place. 

Thus  an  examination  of  ten  thousand  people  in  the  streets  of 
London  revealed  the  fact  that  in  only  four  and  thirteen  one-hun- 
dredths  per  cent  of  people  examined  did  the  jaws  extend  outside 
the  perpendicular  line ;  twelve  and  eighty-seven  one-hundredths 
per  cent  on  the  line,  and  eighty-three  per  cent  inside  the  line. 
In  an  examination  of  three  thousand  English  •  school  children 
(about  ten  years  of  age)  ninety-three  per  cent  possessed  jaws 


*  Talbot:  Developmental  Pathology:  A  Study  in  Degenerative  Evolution. 


TEANSITOEY  STRUCTURES,  21 

inside  the  perpendicular  line;  six  per  cent  on  tlie  line  and  one 
per  cent  outside  the  line.  An  examination  of  eight  thousand 
people  of  Boston  showed  six  per  cent  of  jaws  extending  beyond 
the  perpendicular  line ;  fourteen  per  cent  on  the  line  and  eighty 
per  cent  inside  the  line.  The  examination  of  the  people  of  Bos- 
ton was  made  because  they  more  nearly  represent  those  of  Eng- 
land in  this  country  in  nationality,  environment  and  influence 
of  marriage  and  disease.  It  has  required  more  than  one  thou- 
sand years  to  bring  about  these  results.  A  more  vivid  illustra- 
tion of  this  change  and  one  that  can  be  easily  understood  by 
the  reader  is  that  which  has  taken  place  in  the  negro  in  the  more 
settled  parts  of  America  in  two  hundred  and  fifty  years. 

An  examination  of  the  lowest  negro  type  in  Mississippi  was 
made  for  me  by  Dr.  William  Ernest  Walker  of  New  Orleans. 
His  examinations  of  three  hundred  and  fifty-seven  showed  the 
facial  angle  protruded  beyond  the  perpendicular  line  in  ninety- 
seven  and  five-tenths  per  cent  of  jaws,  while  two  and  five-tenths 
per  cent  of  jaws  examined  were  on  the  line.  An  examination  by 
Dr.  Arthur  E.  Dray  of  six  hundred  and  eighty-six  negroes  in 
Philadelphia,  eighty-three  and  fifty-seven  one-hundredths  were 
found  outside  the  perpendicular  line,  fifteen  and  ninety-five  one- 
hundredths  on  the  line  and  forty-two  one-hundredths  inside  the 
line.  An  examination  of  one  thousand  and  eighty-five  in  Chi- 
cago, fifty-one  and  six  one-hundredths  per  cent  protruded;  thir- 
ty-one and  eight-tenths  were  on  the  line  and  sixteen  and  six- 
tenths  per  cent  were  inside  the  line.  An  examination  of  one 
thousand  negroes  in  Boston  by  Dr.  Eugene  F.  O'Neill  showed 
forty-five  and  four-tenths  per  cent  outside  the  line;  thirty-nine 
and  five-tenths  per  cent  on  the  line  and  fifteen  and  one-tenth  per 
cent  inside  the  line.  It  mil  be  seen,  therefore,  that  in  Northern 
and  in  old  negro  families,  from  race  admixture  and  environment, 
there  is  less  protrusion  and  more  recession  than  in  the  Southern 
pure  negroes.  Arrest  of  the  bones  of  the  face  is  as  common  in 
old  negro  families  in  the  North  as  among  the  Caucasic  races. 

To  further  substantiate  this  claim  a  comparison  of  the  meas- 
urement from  the  outside  of  the  first  molars  of  the  upper  jaws 
of  modern  races  with  ancient  skulls  and  ancient  races  may  be 
here  given.    Examinations  made  by  the  late  Dr.  Mummery,  in 


22 


INTERSTITIAL   GINGIVITIS. 


1860,  of  ancient  British  skulls  measured  2.12  inches,  maximum 
2.62  inches,  with  an  average  of  2.37  inches.  The  modern  Eng- 
lish jaws  measure  minimum  1.88  inches,  maximum  2.44  inches 
with  an  average  of  2.19  inches.  The  jaws  of  people  living  in 
America  measure  minimum  1.75  inches,  maximum  2.52  inches 
with  an  average  of  2.14  inches.  The  difference  between  the  an- 
cient Roman  soldiers  and  modern  Romans  is  the  same  as  that  of 
the  English.'  The  lateral  measurements  of  the  pure  negro  as 
found  in  Mississippi  are  minimum  2.25  inches,  maximum  2.75 
inches,  with  an  average  of  2.51  inches.  The  lateral  diameter  of 
modern  negroes  varies  considerably  owing  to  neurasthenia  in 
the  parents  and  disease  in  the  child.  Some  jaws  measure  as  low 
as  1.75  inches.  The  jaws  of  modern  negroes  residing  in  Boston 
for  many  generations  are  not  unlike  those  of  the  native  whites. 

A  further  demonstration  that  the  jaws  are  becoming  smaller 
is  shown  by  the  disappearance  of  the  third  molar,  or  the  irreg- 
ularties  resultant  on  its  eruption  because  of  want  of  room,  or 
its  eruption  with  pain  for  like  reason.  In  the  primitive  races 
it  is  large  and  well  developed. 

Dr.  Charles  Ward  says  a  ''point  in  which  the  jaws  of  aborig- 
inal tribes,  are,  as  a  rule,  superior  to  those  of  civilized  races  is 
in  the  proportion  of  the  horizontal  ramus.  As  pointed  out  by 
Harrison  Allen,  the  alveolar  and  inferior  border  of  the  jaw  tend 
to  parallelism  in  savages,  while  in  civilized  races  the  symphysial 
height  is  usually  greater  than  the  height  in  the  vicinity  of  the 
molars.  This  may  be  due  to  gradual  degeneration  of  the 
platysma  myoides  muscle.  Of  the  significance  of  the  'ante- 
gonium'  or  'pregonium'  of  the  same  author  I  am  uncertain, 
but  incline  to  the  belief  that  it  is  a  'stigma  of  degeneration.' 
Finally,  an  as  yet  incompleted  study  of  the  relative  proportion 
of  jaw  to  skull  has  convinced  me  that  the  jaws  of  savages  are  not 
only  proportionately  but  actually  heavier  than  our  own,  and 
that  the  ' cranio-mandibular  index,'  as  I  term  it,  which  is  the 
ratio  between  the  weight  of  jaw  and  weight  of  cranium,  rises 
steadily  as  we  descend  from  semi-civilized  to  barbarous  and 
savage  tribes." 

"Thus,  while  the  white  males  examined  gave  an  index  (pro- 


Talbot:  Irregularities  of  the  Teeth. 


TRANSITORY  STRUCTURES.  23 

portion  of  jaw  to  skull)  of  11.8,  the  male  Australians  presented 
an  index  of  15.4. 

'* Absolute  size  of  the  lower  jaw  is  greater  in  savages:  Of 
nine  aborigines,  including  seven  North  American  Indians,  one 
African  and  one  American  negro,  six  Malays  and  five  Austral- 
ians, all  with  beautifully  perfect  teeth,  the  mean  weight  of  the 
jaw  was  102.4  grams.  Of  eighteen  white  males  the  mean  weight 
of  the  jaw  was  only  83.4  grams.  Yet  the  weight  of  the  skull  was 
nearly  alike  in  both  classes,  being  690.9  grams  for  the  aborigines 
as  against  680.5  for  the  whites.  The  weight  of  the  lower  jaw 
compared  with  that  of  the  cranium,  or  the  cranio-mandibular 
Index  is  15.6  for  aboriginal  men  as  against  12.16  for  white  men. 
It  is  46.2  for  the  anthropoid  apes,  our  nearest  living  relatives 
among  mammals. ' ' 

The  change  in  the  two  extremes  of  heads,  the  brachycephalic 
and  the  dolichocephalic  to  the  mesaticephalic  also  produces 
change  in  the  shape  of  jaws  in  like  manner.  Instead  of  the  large 
round  jaw  of  the  brachycephalic  and  the  long  narrow  jaw  of  the 
dolichocephalic,  a  medium  size  jaw  development  also  follows. 


CHAPTER  IV. 

TRANSITOKY   STRUCTURES.^ 
THE    ALVEOLAE    PROCESS. 

The  alveolar  processes  are  situated  upon  the  superior  bor- 
der of  the  inferior  maxilla  and  upon  the  inferior  border  of  the 
superior  maxilla.  These  bones,  considered  a  part  of  the  maxil- 
lary bones  often  so  described  by  anatomists,  should,  however,  be 
considered  from  a  more  careful  study  of  their  physiology  and 
pathology  as  practically  distinct  bones — their  structure,  func- 
tions and  embryology  differ  so  completely  from  the  structure 
and  functions  of  the  maxillary  bones.  The  superior  and  infe- 
rior maxillae  are  (unlike  the  alveolar  processes)  composed  of 
hard,  compact  bone  structure.  The  large,  powerful  muscles 
attached  to  them  indicate  that  powerful  work  is  to  be  accom- 
plished. When  fully  developed  they  retain  their  full  size 
through  life.  The  alveolar  processes  are  composed  of  soft, 
spongy  bone  of  a  cancelloid  structure.  As  early  as  the  eleventh 
week  of  intrauterine  life,  calcification  of  the  deciduous  teeth 
commences,  and  by  the  twentieth  week  calcific  material  is 
abundantly  deposited.  Ossification  is  also  rapidly  progress- 
ing about  the  dental  follicles.  At  birth,  the  sacs  are  nearly  or 
quite  inclosed  in  their  soft,  bony  crypts,  and  the  crowns  of  the 
teeth  upon  their  outer  surface  are  composed  of  enamel,  which 
is  dense  and  hard.  The  embryologic  phases  of  the  dental  shelf 
elsewhere  cited"  indicate  this  development. 

The  alveolar  process,  being  soft  and  spongy,  molds  itself 
about  the  sacs  containing  the  crowns  of  the  teeth  and  about 
their  roots  after  their  eruption,  regardless  of  their  position  in 
the  jaw.  While  the  alveolar  processes  have  grown  rapidly,  they 
have  up  to  this  time  developed  only  sufficiently  to  cover  and 


^Pyorrhoea  Alveolaris.     Paper  No.  2.     The  International  Dental  Journal,  April, 

1896. 
-Talbot:  Irregularities  of  the  Teeth,  page  93. 


TRANSITORY  STRUCTURES,  25 

protect  the  follicles  while  calcification  proceeds.  When  the 
crowns  have  become  calcified  and  the  roots  have  begun  to  take 
in  their  calcific  material,  absorption  of  the  borders  of  the  proc- 
esses takes  place  in  the  order  of  the  eruption  of  the  teeth. 
When  the  teeth  have  erupted,  the  alveolar  processes  develop 
downward  and  upward  with  the  teeth  until  they  attain  the 
depth  of  the  roots  of  the  teeth,  which  extend  in  most  instances 
into  the  maxillary  bones  in  the  anterior  part  of  the  mouth  at 
least,  and  the  upper  and  lower  teeth  rest  at  a  point  in  har- 
mony with  the  rami.  The  depth  at  which  they  penetrate  the 
bone  differs  in  different  mouths.  This  depends  upon  the 
length  of  the  roots  and  the  alveolar  process.  This  in  turn  de- 
pends upon  the  length  of  the  rami.  The  incisive  fossa,  the  canine 
eminence  and  the  canine  fossa  give  evidence  of  this  externally. 
These  sockets  are  lined  with  extensions  of  the  process,  thus 
making  its  upper  border  irregular.  The  crypts  of  the  perma- 
nent teeth  are  located  at  the  apices  of  the  roots  of  the  tem- 
porary teeth.  The  permanent  teeth  have  large  crowns  which 
touch  each  other,  forming  a  line  to  the  posterior  part  of  the  jaw. 
These  teeth,  as  they  erupt,  entirely  absorb  the  alveolar  process 
which  surrounded  the  temporary  teeth,  and  as  the  new  set 
comes  into  place  a  new  process  is  built  up  around  them  for 
their  support. 

The  process  of  absorption  of  the  alveolar  process  and  the 
building  up  of  new  bone  around  the  first  and  second  set  of 
teeth  is  inflammatory.  Tliis  then  is  the  beginning  of  intersti- 
tial gingivitis  in  the  life  of  every  individual.  Whether  this 
primitive  inflammation  continues  through  life  or  not,  will  de- 
pend upon  the  general  health  of  the  person  and  his  ability  to 
keep  his  gums  and  alveolar  process  in  a  normal,  healthy  con- 
dition after  the  temporary  teeth  have  erupted. 

The  permanent  teeth  require  a  deeper  alveolar  process  to 
support  their  roots,  which  are  much  longer  than  those  of  the 
tem.porary  teeth.  Hence  the  difference  in  the  depth  of  the 
vault  of  the  first  and  second  sets  of  teeth. 

The  alveolar  process  of  each  superior  maxilla  includes  the 
tuberosity,  and  extends  as  far  forward  as  the  median  line 
of  the  bone,  where  it  articulates  with  the  process  upon  the 


26 


INTERSTITIAL    GINGIVITIS. 


opposite  side.  It  is  narrow  in  front,  and  gradually  enlarges 
until  it  readies  the  tuberosity,  where  it  becomes  rounded. 

The  process  is  composed  of  two  plates  of  bones  (Fig.  2),  an 
outer  and  an  inner,  which  are  united  at  intervals  by  septa  of 
cancellous  tissue.  These  form  the  alveoli  for  the  reception  of 
the  roots  of  the  teeth.  In  some  cases  the  buccal  and  labial  sur- 
faces of  the  roots  of  healthy  teeth  extend  nearly  or  quite 
through  the  outer  bony  plate  and  are  covered  by  the  peridental 
and  mucous  membranes  only. 

This  plate  is  continuous  with  the  facial  and  zygomatic  sur- 
faces of  the  maxillary  bone.  The  inner  plate  is  thicker  and 
stronger  than  the  outer,  and  is  fortified  by  the  palate  bones. 
The  external  plate  is  irregular  upon  the  outer  surface,  promi- 


FiG.  2. — Diagram  op  the  Superior  :m axillary  Bone  with  the  Teeth  Removed. 


nent  over  the  roots  of  the  teeth,  and  depressed  between  the 
roots  or  interspaces. 

With  the  change  in  the  size  of  jaws  there  is  also  change  in 
the  shape  of  the  vault  and  alveolar  processes.  When  the  den- 
tal arches  are  large,  measuring  from  2.25  to  2.50  inches,  the 
vaults  are  low  and  the  alveolar  processes  are  short  and  thick, 
not  only  giving  stability  to  the  teeth,  but  also  plenty  of  nour- 
ishment. Now  that  the  dental  arches  are  growing  smaller,  with 
an  average  of  from  1.90  to  2.00  inches,  the  vaults  are  higher  in 
proportion,  the  alveolar  processes  long  and  thin.  This  renders 
the  teeth  and  jaws  more  susceptible  to  trophic  changes  and 
hence  to  disease.  The  alveolar  process  in  the  anterior  part  of 
the  mouth,  in  which  the  incisors  and  cuspids  are  situated,  is 
much  thinner  than  in  the  posterior  parts. 


TKANSITORY  STEUCTUEES.  27 

The  sockets  for  the  incisors  and  cuspids  are  conical  and 
much  larger  than  any  of  the  other  single  sockets.  The  alveolar 
process  is  longer  and  thinner  than  at  any  of  the  other  teeth. 
The  sockets  for  the  bicuspids  are  flattened  upon  their  anterior 
and  posterior  surfaces,  and  near  the  apices  they  are  frequently 
bifurcated.  The  sockets  of  the  molars  are  large  at  the  open- 
ings. About  the  middle  of  their  length,  however,  they  are 
divided  into  three  smaller  sockets  for  the  reception  of  the  roots. 
In  the  case  of  the  third  molar  the  number  of  sockets  ranges 
from  one  large  cavity  to  three  or  four  of  smaller  size.  When 
disease  attacks  the  tissues,  destruction  is,  therefore,  more  rapid 
in  its  progress  in  the  anterior  parts  of  the  mouth  than  in  the 
posterior,  where  the  processes  are  thicker  and  more  nourish- 
ment is  required. 

The  septa  are  very  thin  at  the  margin  and  gradually  increase 
in  width  to  the  middle  of  the  jaw,  where  they  become  thicker, 
and  are  finally  lost  in  the  substance  of  the  jaw.  Some  septa 
are  thicker  than  others,  and  where  two  teeth  are  mdely  sepa- 
rated, the  width  of  the  septa  naturally  corresponds  to  the  space 
between  the  teeth. 

What  is  true  in  regard  to  a  change  in  the  size  of  the  jaws  is 
also  true  in  respect  to  the  shape  of  the  crowns  of  the  teeth. 
While  they  are  not  growing  smaller  in  proportion  to  the  size  of 
the  jaws,  they  are  changing  shapes.  Once  they  were  quite  bell- 
shaped,  giving  considerable  space  between  the  roots  for  a  thick 
alveolar  process,  thus  rendering  support  to  the  peridental  and 
mucous  membranes,  now  the  shape  has  changed.  The  proximal 
surfaces  are  almost  straight,  lessening  the  width  and  thus  allow- 
ing only  for  a  thin  septum,  with  barely  sufficient  surface  to  sup- 
port the  tissues  without  material  blood  and  nerve  supply. 

The  sockets  are  lined  with  a  thin  plate  of  compact,  bony 
substance,  extending  from  the  outer  and  inner  plates  of  the 
alveolar  process  to  the  apex,  where  there  are  small  openings 
for  the  entrance  of  the  nerve  and  blood  vessels  for  the  nour- 
ishment of  the  teeth. 

The  bony  plate  has  upon  its  inner  surface  the  elastic  peri- 
dental membrane,  which  acts  as  a  cushion  for  the  teeth,  while 
it  is  surrounded  by  a  spongy  bone. 


28 


INTEKSTITIAL    GINGIVITIS. 


The  teeth  are  held  firmly  in  their  alveolar  sockets  by  the 
peridental  membrane.  Teeth  with  one  conical  root,  and  those 
with  two  or  more  perpendicular  roots,  are  retained  in  position 
by  an  exact  adaptation  of  the  tissues.  Teeth  having  more  than 
one  root  and  those  bent  or  irregular,  receive  support  from  all 
sides  by  reason  of  their  irregularity.  Fig.  3  (a  section  of  the 
jaw  of  a  cat)  illustrates  the  relative  position  of  the  teeth,  peri- 
dental membrane  and  alveolar  process  to  each  other. 

After  the  removal  of  the  permanent  teeth  the  alveolar 
process  is  entirely  absorbed.  Fig.  4  shows  how  the  absorption 
takes  place.  The  teeth  have  all  been  removed  from  the  supe- 
rior maxilla  and  the  alveolar  process  has  been  entirely  absorbedc 


Fig.  3. — Ground  Section  of  Jaav  and  Teeth  of  Cat.     (Andrews.) 

The  molars  on  the  lower  jaw  having  been  extracted,  absorption 
of  the  alveolar  process  has  resulted  in  marked  contrast  with  the 
anterior  alveolar  process,  which  remains  intact  and  holds  the 
teeth  firmly  in  place.  It  is,  hence,  evident  from  the  changes 
which  occur,  from  the  first  development  of  the  teeth  to  their 
final  extraction,  that  the  alveolar  process  exists  solely  to  pro- 
tect the  teeth  in  their  crypts  during  development  and  after 


TRANSITORY  STRUCTURES. 


29 


eruption.  After  the  temporary  teeth  are  in  place  the  alveolar 
process  remains  unchanged  (except  by  gradual  enlargement  in 
harmony  with  the  growth  of  the  maxillary  bones)  until  about 
the  sixth  year,  when  the  second  set  appears.  The  crowns  of 
the  permanent  teeth  require  more  space  than  those  of  the  tem- 


FiG.  4. — Plaster  Casts  of  the  Superior  and  Inferior  Jaws  ix  Position'.  All  the 
Teeth  Have  Beex  Eemoved  ox  the  Upper  Jaw,  axd  the  Molars  and  Second 
Bicuspids  ox  the  Lower  Jaav.  Absorption  of  the  Jaavs  Where  Teeth  Have 
Been  Eemoved  Well  Advanced. 

porary  set;  and  the  alveolar  process  must  necessarily  enlarge 
to  accommodate  them.  This  enlargement  of  the  alveolar  proc- 
ess is  caused  chiefly  by  formation  of  the  crowns  of  the  perma- 
nent teeth  before  eruption,  and  to   a  limited  extent  only  by 


Fig.  5.- 


-The  Anterior  Alveolar  Process  Excessively  Developed,  Carrying 
the  Teeth  Upwards. 


growth  of  the  maxillary  bones.  These  may  cease  development 
at  any  period  of  the  life  of  the  individual,  or  continue  as  late 
as  the  thirty-sixth  j^ear.  As  diameter  of  the  crowns  of  the  per- 
manent teeth  form  a  larger  circle  than  that  of  tlie  maxillarv 


30  INTERSTITIAL    GINGIVITIS. 

bones,  the  alveolar  process  must  necessarily  increase  its  diam- 
eter and  present  large  spaces  between  the  roots  of  the  teeth 
for  the  development  of  the  alveolar  process. 

The  process  is  solely  for  retaining  the  teeth,  and  if  for  any 
reason  the  dental  follicles  should  not  be  present,  and  the  tooth 
should  not  erupt,  or  if  it  should  be  extracted  early,  the  process 
would  not  be  developed  at  that  point.  In  my  collection  of  mod- 
els are  cases  of  arrested  development  of  the  alveolar  process, 
caused  by  the  lack  of  bicuspid  and  lateral  incisor  germs,  and  by 
extraction  of  deciduous  and  permanent  teeth. 

If  one  or  more  teeth  w^ere  not  to  antagonize,  the  alveolar 
process  would  extend  beyond  the  natural  border,  carrying  the 
teeth  with  it.  A  marked  illustration  of  this  is  seen  where  the 
molars  are  decayed  to  the  gum  and  the  roots  remain.  The 
vascularity  of  the  process  may  be  such  that  hypertrophy  re- 
sults. Excessive  development  of  the  alveolar  process  is  fre- 
quently observed  by  everj^  practitioner  in  connection  with  the 
anterior  inferior  teeth.  When  the  articulation  is  normal,  occlu- 
sion of  these  teeth  never  takes  place.  Frequently  (especially 
in  patients  from  six  to  twelve  years  of  age)  these  teeth  extend 
to  and  occlude  with  the  mucous  membrane  of  the  hard  palate. 
Such  a  case  is  illustrated  in  Fig.  5.  This  model  is  taken  from 
the  jaw  of  a  person  thirty-seven  years  of  age,  but  this  excessive 
development  took  place  between  the  ages  of  six  and  twelve 
years,  since  at  that  period  the  vascularity  of  the  tissues  is  more 
vigorous,  and  the  development  of  the  process  more  formative 
than  at  any  period  subsequent  to  the  development  of  the  first 
permanent  teeth. 

In  one  patient  under  observation  the  incisors  and  cuspids, 
together  with  their  alveolar  process,  are  situated  upon  the 
external  surface,  while  the  bicuspids,  molars  and  their  alveolar 
process  are  located  upon  the  inner  border  of  the  jaw.  In  an- 
other patient,  the  alveolar  process  failed  to  cover  the  roots  of 
the  bicuspids  and  molars  upon  the  outer  surface,  the  teeth  hav- 
ing forced  themselves  into  a  larger  circle  through  the  alveolar 
process  by  the  contact  of  the  crowns.    The  roots  in  this  patient 


Dental  Surgery,  page  44. 


TKANSITORY  STRUCTURES.  31 

can  easily  be  outlined  by  the  finger  througli  the  mucous  mem- 
brane, the  outer  plate  of  the  alveolar  process  barely,  if  at  all, 
covering  them.  Tomes'  illustrates  a  patient  of  faultj"  develop- 
ment of  the  outer  plate  of  the  alveolar  process,  exposing  the 
crown  of  the  temporary  teeth.  This  occurred  in  a  hydro- 
cephalic. I  have  a  number  of  models  shomng  the  anterior  alve- 
olar process  projecting  beyond  the  normal  position  through  the 
forward  movement  of  the  molars.  This  may  be  due  to  a  nat- 
ural movement  of  the  molars  forward,  or  the  process  may  be 
forced  forward  by  the  -improper  occlusion  of  the  jaws.  The 
teeth  are  moved  from  one  position  to  another  simply  by  the 
force  consequent  upon  absorption  and  deposition  of  bone.  This 
is  noticeable  in  the  spaces  between  the  centrals,  when  the  alve- 
olar process  develops  to  a  larger  circle  than  is  necessary  to 
accommodate  the  teeth.  The  alveolar  processes  are  influenced 
in  one  direction  or  the  other  by  the  pressure  of  articulation. 
This  results  from  inharmonious  development  of  the  jaws.  The 
teeth  may  come  together  in  such  a  manner  as  to  throw  the 
alveolar  processes  either  to  the  right  or  the  left,  thus  produc- 
ing a  full,  round  arch  upon  one  side  of  the  jaws,  and  a  perfectly 
flat  or  straight  arch  upon  the  other.  Occasionally  both  upper 
and  lower  alveolar  processes  are  carried  forward  in  the  same 
manner.  The  alveolar  process  upon  the  lower  jaw  is  more 
liable  to  be  found  upon  the  inner  border  of  the  jaw  than  is  the 
upper  alveolar  process,  as  the  inferior  maxilla  is  larger  and 
more  dense  than  the  superior,  and  when  the  teeth  are  once  in 
position  upon  the  lower  jaw  they  are  not  so  liable  to  subse- 
quent change.  Owing  to  this  the  teeth  of  the  superior  maxilla 
do  not  form  so  great  a  circle.  This  causes  the  teeth  upon  the 
sides  of  the  jaw  to  conflict,  and  the  lower  teeth  and  alveolar 
processes  to  be  carried  in,  while  the  anterior  teeth  of  the  lower 
jaw  are  held  inside  of  the  superior  anterior  teeth,  thus  carry- 
ing the  alveolar  processes  inward. 

The  teeth  are  continually  changing  their  positions  in  the 
mouth.  This  is  as  often  beneficial  as  it  is  detrimental.  That 
the  teeth  may  perform  their  full  function,  they  should  not  only 
remain  firmly  in  the  alveolar  process,  but  they  should  also 
antagonize  properly.    The  teeth  may  be  compared  to  the  bricks 


32 


INTERSTITIAL    GINGIVITIS. 


in  an  arch.  Eemove  a  brick  and  the  arch  falls  to  pieces.  It  is 
frequently  found  that  the  teeth  do  not  articulate  properly;  by 
a  slight  movement,  or  by  cutting  away  the  grinding  surfaces,  a 
better  articulation  may  be  secured.  When  this  operation  is  per- 
formed, the  teeth  move  in  their  sockets  by  absorption  and  depo- 
sition of  bone,  demonstrating  the  fact  that  the  process  changes 
in  shape  and  substance.  Ziegler*  says  absence  of  functional  use 
is  a  frequent  cause  of  premature  lacunar  absorption  of  the 
bone.  This  form  of  atrophy  from  disuse  occurs  not  only  when 
a  limb  or  a  part  of  a  limb  is  deprived  of  its  normal  activity, 
but  also  when  portions  of  a  single  bone  cease  to  perform  their 
function  of  support,  and  finally,  like  all  the  bones  of  the  body,  as 
age  advances,  normal  or  physiologic  absorption  takes  place, 
while  the  teeth  are  still  in  the  jaws.     Unlike  other  bones  of  the 


Fjg.  6. — Hypertrophy  of  the  Entire  Alveolar  Process. 

body,  however,  the  absorption  of  the  alveolus  progresses  to  a 
greater  extent  because  of  the  unstable  condition  of  the  struc- 
tures. 

From  what  has  already  been  said  of  the  vascularity  of  the 
alveolar  process,  it  is  evident  that  hypertrophy  of  the  tissue  may 
ensue  from  an  unbalanced  nervous  system  and  from  simple  irri- 
tation of  varying  degree.  This  unbalanced  nervous  system  may 
act  directly  upon  the  pituitary  body,  producing  hypophyseal 
disorders  which  in  turn  aifect  the  growth  of  the  jaws  and  alve- 


*  A  Text-Book  of  Special  Pathological  Anatomy,  page  145. 


TRANSITORY  STRUCTURES. 


33 


olar  process.  The  irritation  consequent  upon  the  eruption  of 
the  teeth,  together  mth  the  excessive  blood  supply,  are  both 
primal  causes  of  overbuilding  of  tissue,  i.  e.,  hyperplasia. 

The  ragged  roots  of  the  temporary  teeth,  produced  by  ab- 
sorption of  the  gases  from  the  putrescent  pulps,  and  the  pres- 
sure of  the  permanent  crowns  against  the  tissues,  produce  suf- 
ficient stimulation  to  excite  physiological  action.  Tissue-build- 
ing generally  is  seen  in  connection  with  all  the  teeth,  and  the 
process  becomes  unnaturally  thick,  the  teeth  frequently  are 
carried  in  one  direction  and  another;  cementosis  of  the  roots 
of  the  teeth  and  hypertrophy  of  the  process  result. 

In  cases  of  hypertrophy  of  the  alveolar  process,  enlarge- 
ment is  associated  with  the  inner  plate  of  the  alveolar  process. 
In  patients  coming  under  my  observation  the  inner  plate  in 


Fig.   7. — Hypertrophy  of  the  Alveolar  1'rocess  Around  the  Left 
Superior  Molar  Teeth. 


most  is  the  part  of  the  alveolar  process  affected  (Fig.  6  case). 
The  outer  plate,  although  quite  irregular  from  the  arrange- 
ment of  the  teeth,  is  usually  normal  in  thickness.  This  dis- 
parity in  the  two  plates  of  the  alveolar  process  is  due  to  the 
fact  that  the  inner  plate  of  the  alveolar  process  possesses  a 
large  blood  supply,  the  posterior  or  descending  palatine  arter- 
ies furnishing  the  ossific  material.     I  have  observed  but  few 


34  INTERSTITIAL    GINGIVITIS. 

patients  where  hypertrophy  has  extended  to  and  included  the 
outer  plate.  When  the  outer  plate  becomes  involved  the  alve- 
olar process  assumes  a  very  thick  condition.  Occasionally 
hypertrophy  will  affect  one  side  only  or  one  distinct  locality 
(Fig.  7).  In  this  patient  the  enlargement  is  upon  the  left  side 
and  extends  from  the  first  bicuspid  posterior  to  and  including 
the  maxillary  tuberosity.  Instead  of  the  force  being  directed 
inward,  as  is  generally  the  case,  the  process  is  forced  outward 
and  backward.  This  enlargement  occurred  previously  to  the 
development  of  the  second  and  third  molars.  The  alveolar 
process  extends  downward  and  occludes  with  the  teeth  upon 
the  lower  jaw,  thus  preventing  the  molars  from  erupting. 

The  causes  which  produce  hypertrophy  of  the  alveolar  proc- 
ess are  those  due  to  an  unstable  nervous  system.  This  subject 
is  discussed  in  my  work  on  "Developmental  Pathology :  A  Study 
in  Degenerative  Evolution." 

(Late  researches  have  shown  that  the  hypophysis  and  its 
disorders  have  much  to  do  with  arrest  and  excessive  develop- 
ment of  the  body  as  a  whole  or  of  particular  organs  or  struc- 
tures of  the  body.  The  author  many  years  ago  called  the  atten- 
tion of  the  profession  to  the  fact  that  an  unstable  nervous  sj^s- 
tem  of  the  parent  or  disease  in  the  child  after  birth  produced 
excessive  or  arrest  of  development  of  the  tissues.  It  is  possible 
that  the  unstable  nervous  system  of  the  parent  or  the  diseases 
of  the  child  act  first  upon  the  pituitary  body,  which  in  turn 
acts  upon  the  tissues  themselves  or  that  they  both  act  together.) 


CHAPTER  V. 

THE  ALVEOLAR  PROCESS  UNDER  THE  MICROSCOPE. 

Under  the  microscope,  two  systems  of  Haversian  canals  are 
seen  in  the  alveolar  process.  Kolliker^  describes  these  as  fol- 
lows : 

"The  Haversian  canals  are  of  two  kinds.  One  with  the 
regnlar  lamellae  system  surrounding  it,  and  the  other,  the  so- 
called  Volkmann's  canals,  containing  the  perforating  vessels 
from  Von  Ebner,  which  have  no  surrounding  lamellae,  but  sim- 


YiQ.  8. — Section  of  Bone  Showing  Blood  A^essels  of  Vok  Ebner  (Kolliker). 

ply  penetrate  through  the  layers  of  bone.  Volkmann's  canals 
are  present  in  all  tubular  bones  in  old  and  young.  While  espe- 
cially present  in  the  outer  basal  lamellae,  they  occur  also  in  the 
interstitial  leaflets  and  in  the  inner  chief  lamellae  as  well  as  in 
the  periosteal  layers  of  the  skull  bone.  Here  their  number  is 
very  variable  (Fig.  8).  They  run  partly  transversely  or 
obliquely,  and  alsa  partly  longitudinally,  through  the  lamellas. 


^  Handbuch  der  Gewebelehre,  page  272. 


36 


INTERSTITIAL    GINGIVITIS. 


Many  of  these  canals  open  in  the  outer  or  inner  surfaces  of  the 
substantia  (compact  substance),  and  also  here  and  there  in  the 
Haversian  canals,  and  form  altogether  usually  a  wide-meshed 
irregular  network.  In  their  structure  they  are  sometimes 
smooth  and  sometimes  furnished  with  dilatations  and  angles 
projecting  in  and  out  in  profile.  The  widest  has  a  diameter  of 
100  micrometers  or  more,  and  the  narrowest  not  more  than  10 
or  20  micrometers,  and  there  are  still  narrower  ones  which  are 
altogether  obliterated,  appearing  like  rings  or  circular-formed 


Fig.  9. — Section  of  Bone  (Higher  Magnification)  Showing 
Blood  Vessels  of  Von  Ebner. 


structures  without  any  lumen,  or  like  those  far  from  rare  oblit- 
erated true  Haversian  canals  first  described  by  Tomes  and 
de  Morgan.  The  contents  of  the  Volkmann  canals  are  the  same 
as  the  Haversian  canals." 

Fig.  8  is  a  cross  section  of  the  medulla  of  a  calcified  human 
humerus  slightly  changed.  The  outer  lamellae  contains  a  large 
number  of  Volkmann 's  canals  running  longitudinally  and  trans- 
versely and  extending  through  the  outer  plate  of  bone  into  the 
periosteum.     Fig.  9,  the  cross  section  of  the  section  seen  in 


THE  ALVEOLAR  PROCESS  UNDER  THE  MICROSCOPE. 


37 


Fig.  8,  shows  these  canals  more  highly  magnified.  The  Haver- 
sian canals  are  large  romid  spaces  (Fig.  10),  containing  a  sin- 
gle artery  and  vein.  The  fine  hair-like  spaces  running  from 
these  large  spaces  are  the  canalicnli.  The  dark  spots  circulat- 
ing each  Haversian  canal  are  the  lacunae.  The  canalicnli  run 
from  one  lacunae  to  another  or  into  a  Haversian  canal  or  they 
anastomose  with  each  other.  The  rings  of  bone  about  each 
Haversian  canal  are  called  lamella.  The  lacuna'  seem  to  be 
about  uniformly  distributed  throughout  the  bone.     The  spaces 


-^ 


-^■ 


^",^''*"* 

^/V^*'    ■^ 


Fjg.  10. — Transverse  Section  of  the  Diaphysis  of  the  Humerus 

Magnified  350  Times. 

A,  Haversian  Canal.     Dark  Spaces,  Lacunar. 

Hair-like  Spaces,  Canaliculi. 

Fig.  11. — Longitudinal  Section  of  Bone  Magnified  100  Times. 

between  the  lacunae  and  canaliculi  are  filled  with  lime  salts. 

A  longitudinal  section  of  bone  (Fig.  11)  is  similar  in  appear- 
ance to  the  cross  section.  Instead  of  the  lacunae  being  arranged 
in  rows  around  the  Haversian  canals  they  are  parallel.  It  will 
be  noticed  that  the  Haversian  canals  run  in  different  directions 
and  communicate  ^\ith  each  other  at  certain  intervals.  The 
foregoing  description,  with  illustrations  from  Kolliker,  is  essen- 
tially that  of  the  minute  anatomy  of  the  alveolar  process. 


CHAPTER  VL 

THE    GUMS.    PERIOSTEUM,    MUCOUS    AND    PERIDENTAL    MEMBRANES 
UNDER   THE  MICROSCOPE. 

GUMS   AND    MUCOUS    MEMBRANE. 

The  tooth,  according  to  Minot/  is  a  papilla  which  projects 
into  the  epidermis,  and  ossifying  in  a  particular  way,  changes 
into  ivory  around  the  soft  core  or  pulp.  To  the  papilla  the  epi- 
dermis adds  a  layer  of  enamel.  The  tooth  proper  unites  with 
a  small  plate  of  dermal  bone  at  its  base.  By  a  modification  on 
the  jaw,  the  epidermis  first  grows  into  the  dermis,  and  then 
the  dermal  tooth  papilla  is  developed.  The  teeth  were  primi- 
tively organs  of  the  skin  and  widely  developed  over  the  sur- 
faces of  the  body.  As  the  mucous  membrane  is  practically  a 
continuation  of  the  skin,  it,  in  accordance  Avith  the  law  of  indi- 
viduation, became  specialized  and  lost  some  of  the  functions 
of  the  skin  while  developing  the  others  to  greater  perfection. 

The  mucous  membrane  lines  the  cavity  of  the  mouth,  the 
nose,  and  extends  through  the  larynx  into  the  lungs  and  through 
the  oesophagus  into  the  stomach.  It  covers  the  tongue,  jaws, 
alveolar  process,  dipping  down  between  the  necks  of  the  teeth 
and  the  alveolar  process  as  far  as  the  peridental  membrane, 
leaving  a  free  space  between  the  membrane  and  the  teeth 
through  its  entire  length. 

It  consists  of  two  layers  (Fig.  12),  the  epithelium  (A)  and 
corium  (B),  separated  by  the  basement  membrane  (C).  The 
epithelium  is  composed  of  the  epitheUal  cells :  First,  one  row  of 
columnar  cells  (D)  situated  upon  the  basement  membrane  (C) ; 
second,  two  rows  of  six-sided  prickle  shells  (E) ;  third,  two  rows 
of  six-sided  cells  (F) ;  fourth,  two  or  three  rows  of  sciuamous 
cells  (G)  ;  and  fifth,  four  or  five  rows  of  flattened  dead  cells  (H), 
which  were  originally  the  columnar  cells  upon  the  basement 


^  Embryology,  page  481. 


GUMS  AXD  MUCOUS  MEMBRANE. 


39 


membraue.  The  young  new  cells  are  the  columnar  cells  which 
pass  from  one  stage  to  another,  changing  their  shapes  until  they 
eventually  become  dead  cells  and  are  exfoliated  from  the  surface 
of  the  tissue.  The  basement  membrane  (C)  is  made  up  of  fibers 
running  longitudinally,  from  papillae,  which  allow  the  tunica 
propria  containing  blood  vessels  and  nerves  to  pass  up  into  the 
epithelium  structure.       w 


--^-'•^■-  -"-" 


Fig.  12. — Diagrammatic  Tt.t.ustbatiox  of  the  Epithelium  and  SrsMrcors  Layers 
OF  THE  Mrcous  Membrane. 

A,  Epithelium.  B,  Corium.  C,  Basement  Membrane.  D,  Columna  Cells.  E. 
Prickle  CeUs.    F,  Six-sided  CeUs.    G.  Squamous  Cells.    H.  Flattened  Dead  Cells. 

The  corium  (B)  (which  lies  below  the  basement  membrane) 
is  composed  of  alveolar  comiective  tissue,  white  yellow  fibrous 
connective  tissue,  muscular  fibers,  nerves,  blood  vessels  and 
lymphatics.  It  is  inade  up  of  the  tunica  propria  and  the  sub- 
mucosa. 

The  tunica  propria  (beautifully  shown  in  Fig.  13)  consists 


40  INTERSTITIAL    GINGIVITIS. 

of  interlacing  connecting  fibers  interspersed  with  nmcli  elastic 
fibrous  tissue.  This  tissue  penetrates  the  epithelial  layer  in  the 
form  of  cone-shaped  papillae,  varying  in  length  with  the  thick- 
ness of  the  epithelium.  This  layer  being  the  thickest  at  the 
gum  margin  (E),  these  papillae  are  the  longest  and  largest  at 
this  locality.  The  fibers  of  the  tunica  propria  pass  gradually 
into  the  submucous  membrane  (G),  and  from  there  into  the  peri- 
osteum and  peridental  membrane  (M),  so  that  it  is  difficult  to 
determine  the  mucous  capacity  line  of  demarcation  separating 
the  ditferent  structures.  The  submucosa  is  composed  of  fibrous 
connective  tissue  of  a  much  less  compact  variety.  This  struc- 
ture is  attached  to  the  bones  through  the  periosteum  and  peri- 
dental membrane.  In  this  structure  the  glands,  blood  vessels, 
nerves,  fat  cells,  etc.,  occur. 

The  larger  blood  vessels  (K)  are  found  in  this  structure. 
From  these  large  blood  vessels  small  capillaries  extend  to  the 
tunica  propria.  It  is  here  that  inflammation  commences  in 
interstitial  gingivitis  when  due  to  local  irritation.  Numerous 
veins  accompany  each  artery,  and  lymphatics  form  a  network 
around  them.  Small  nerve  filaments  are  also  in  this  structure, 
which  pass  through  the  tunica  propria  and  into  each  papilla  in 
connection  with  the  capillaries.  The  terminal  nerve  fibers  come 
in  contact  with  the  muscular  fibers,  so  that  there  is  direct  com- 
munication by  blood  vessel  and  nerve  throughout  the  muco^ip 
membrane  from  the  nose,  stomach  and  lungs.  The  gum  tissue 
is  very  thick  and  made  up  of  fibrous  tissue  running  in  three  or 
four  directions,  rendering  it  dense,  tough  and  hard.  The  mem- 
brane thus  differs  from  the  same  structure  in  other  parts  of  the 
body.  On  account  of  these  numerous  fibers,  this  structure  is 
bound  tightly  to  the  alveolar  process.  The  gum  tissue  acts  as 
a  cushion  and  protection  from  irritation  which  may  arise  from 
hard  substances  being  taken  into  the  mouth.  As  this  membrane 
passes  and  coalesces  with  the  membrane  of  the  lips  and  cheeks, 
it  becomes  much  thinner  and  less  dense.  In  the  center  of  the 
tooth,  the  parallel  fibers  in  the  tunica  propria  are  composed  of 
flattened  fasciculi  of  connective  tissue.  There  are  three  sets 
of  fibers — those  which  run  vertically,  those  which  radiate  and 
are  fan-shaped,  and  those  which  are  horizontal. 


X  75.     A.  A.  obj.     Zeiss.     Micro-x>li"tographs,  reduced  one-third. 

Fig.  13. — Lox&iTUDixAL  Section  of  Tooth  and  Gum  Tissue.     Dog. 

D.  Dentine.  E.  Epithelial  Tissue.  G,  Submucous  Membrane.  K,  Capillaries.  M, 
Fibrous  Tissue.  V,  Violent  Inflammation.  AA,  Point  of  Union  of  Epithelial  Tissue 
and  Peridental  Membrane.  EE,  Space  Pocket  from  Want  of  Union  of  the  Epithelial 
Fold. 


42  INTERSTITIAL    GINGIVITIS. 

The  mucous  membrane,  like  tlie  alveolar  process  and  peri- 
dental membrane,  is  composed  of  very  unstable  tissue.  It 
changes  its  structure,  blood  vessels  and  nerve  system  as  often 
as  the  other  structures.  Its  blood  vessels  and  nerve  system  are 
continually  renewing  connective  tissue,  periosteum  and  periden- 
tal membrane. 

A  difference  is  noted  in  the  structure  of  the  papillary  layer 
in  man  and  the  lower  animals,  such  as  the  dog,  the  sheep  and 
the  calf.  In  man  the  gum  tissue  is  not  so  thick,  therefore  the 
papillae  are  broader  and  shorter,  while  in  the  lower  animals  the 
papillae  are  narrow,  long  and  more  closely  set  together.  Blood 
vessels  and  nerves  are  not  so  numerous  and  close  together  in 
man  as  in  animals. 

THE   PERIOSTEUM   AND    PERIDENTAL    MEMBRANE. 

The  periosteum  is  a  fibrous  tissue  covering  the  outer  surface 
of  the  alveolus.  The  peridental  membrane  is  composed  of  simi- 
lar structures  covering  the  roots  of  the  teeth  and  lining  the 
inner  wall  of  the  alveolus.  They  are  both  derived  from  the 
mesoblastic  layer.  For  this  reason  there  can  be  very  little  dif- 
ference in  the  character  of  the  structure  of  each,  except  so  far 
as  function  is  concerned.  The  periosteum  is  made  up  of  four 
different  kinds  of  fibers.  An  outer  layer  of  coarse,  w^hite  fibrous 
tissue,  an  inner  layer  of  fine,  white  fibrous  tissue,  elastic  fibers, 
and  penetrating  fibers  (fibers  of  Sharpey). 

The  fibers  of  the  periosteum  are  coarser  than  those  of  the 
peridental  membrane.  The  coarser  fibers  run  parallel  with  the 
alveolar  process  (J)  over  the  border  and  extend  as  far  as  the 
union  of  the  epithelial  layer  (E)  and  the  periosteum  (H),  Fig. 
14.  (^'The  dental  ligament,"  Black.-)  The  finer  fibers  run  in 
all  directions  and  enter  the  alveolar  process  at  every  point.  If 
a  section  of  the  alveolar  process  treated  with  acids  or  a  section 
affected  by  halisteresis  or  osteomalacia  be  placed  under  the 
microscope,  the  fibers  are  seen  to  retain  the  original  shape  of 
the  bone. 


American  System  of  Dentistry,  page  663. 


X  75.     A.  A.  obj.     Zeiss.     Micro-photographs,  reduced  one-third. 

Fig.  14. — Longitudinal  Section  of  Tooth,  Alveolar  Process,  Peridental  Mem- 
brane AND  Periosteum.     Normal  Tissue.     Sheep. 

B,  Dentine.  C,  Cementum.  E,  Epithelial  Tissue.  G,  Submucous  Membrane. 
H,  Periosteum.  J,  Alveolar  Process.  K,  Capillaries.  L,  Haversian  Canals.  M, 
Fibrous  Tissue,    AA,  Point  of  Union  of  Epithelial  Tissue  and  Peridental  Membrane. 


X  75.     A.  A.  obj.     Zeiss.     Micro-photographs,  reduced  one-third. 

Fig.  15. — Cross  Section  of  Tooth,  Alveolar  Process,  Peridental  Membrane 
AND  Periosteum.     Normal  Tissue.     Dog. 

B,   Dentine.      C,    Cementum.      D,    Pnlp.      H,    Periosteum.      J,    Alveolar   Process. 
K,  Capillaries.     M,  Fibrous  Tissue.     U,  Nerve  Tissue.     CT,  Connective  Tissue. 


GUMS  AND  MUCOUS  MEMBRANE.  45 

The  fibers  of  the  periosteum,  therefore,  are  continued 
throughout  the  process  from  the  periosteum  on  the  one  side  to 
the  peridental  memljrane  on  the  other.  This  is  also  illustrated 
in  the  mouths  of  persons,  where  (after  wearing  artificial  den- 
tures for  a  short  time)  heat  produces  absorption  of  the  lime 
salts,  leaving  the  fibrous  tissues  intact. 

The  periosteum  is  abundantly  supplied  with  blood  vessels 
which  anastomose  with  each  other  and  enter  the  alveolar  proc- 
ess at  the  Haversian  canals.  The  plexus  of  blood  vessels  is  much 
larger  proportionately  in  connection  with  the  alveolar  process 
than  with  other  bones  of  the  body,  owing  to  its  transitory 
nature. 

The  peridental  meml)rane  commences  at  the  margin  of  the 
epithelium  at  the  neck  of  the  tooth  AA,  Fig  14,  and  is  attached 
directly  to  the  cementum.  This  membrane  has  various  func- 
tions :  First,  it  fills  the  space  between  these  two  structures, 
forming  a  cushion  for  the  teeth  to  rest  upon;  second,  like  the 
alveolar  process,  it  is  present  only  when  the  teeth  are  present, 
and  therefore  develops  with,  the  alveolar  process  when  the  first 
teeth  erupt,  it  is  entirely  lost  when  the  temporary  teeth  are 
shed,  is  restored  with  the  eruption  of  the  second  set,  and  when 
the  permanent  teeth  are  extracted  it  disappears  with  the  alve- 
olar process  completely;  third,  it  furnishes  the  nourishment  for 
the  teeth  while  they  are  in  position  in  the  jaw,  and  holds  them 
in  their  sockets. 

The  fibrous  tissue,  in  its  earliest  stages  comprises  nearly  all 
or  quite  all  of  that  portion  of  the  jaw  which  eventualh^  becomes 
the  alveolar  process.  Calcification  begins  at  the  center  of  the 
jaws  and  gradually  closes  in  upon  the  fibrous  membrane  until 
it  becomes  the  thickness  of  a  sheet  of  paper.  In  young  persons 
the  membrane  is  much  thicker  than  in  old  age,  since,  as  age 
advances,  the  osteoblasts  on  the  one  hand  and  the  cementoblasts 
on  the  other  send  out  new  material  and  each  wall  closes  in  upon 
the  membrane,  which  becomes  very  thin  in  old  age  and  almost 
lost. 

The  fibers  which  compose  this  membrane  extend  in  all  direc- 
tions; some  crossT/ise  penetrating  the  cementum,  on  the  one 
hand,  and  the  alveolar  process  on  the  other.    In  a  general  way. 


46  INTERSTITIAL    (ilNGIVITIS. 

since  the  fibers  extend  tlirougii  the  alveolar  wall,  they  are  more 
closely  adherent  to  the  bone  than  to  the  cenientum,  and  usually 
cling  to  the  latter  when  the  tooth  is  removed.  It  will  be  observed 
that  these  fibers  do  not  enter  the  alveolar  process  uniformly  as 
claimed  by  Gray'  and  Pierce*,  like  tacks  or  nails  driven  regu- 
larly into  a  board  (the  ''fibers  of  Sharpey"  Fig.  14),  but  vary 
as  to  quantity  in  different  localities.  In  some  localities  they 
penetrate  in  large  quantities  and  almost  surround  a  piece  of 
alveolar  process,  while  a  few  fibers  penetrate  but  a  short  dis- 
tance. In  some  places,  they  can  be  traced  almost  through  the 
alveolar  process.  These  fibers  are  much  finer  in  man  (Fig.  15) 
than  in  the  lower  animals  (Fig.  14,  dog).  In  connection  with 
the  fibers  which  pass  into  the  alveolar  process  are  numerous 
blood  vessels.  Others  run  diagonally,  and  still  others  length- 
wise, all  making  up  a  tissue  which  holds  the  tooth  in  position  in 
the  jaw.  The  fibers  enter  the  peridental  membrane  at  all  points 
of  the  process,  from  its  margin  to  the  apex  of  the  roots.  The 
elasticity  of  this  membrane  is  so  great  that  in  correcting  irregu- 
larities a  tooth  may  be  turned  from  one-fourth  to  one-half 
around  without  breaking  the  fibers.  The  elasticity  is  greatest 
in  youth.  As  age  advances,  the  membrane  grows  thinner  and 
thinner  until,  late  in  life,  there  is  almost  a  bony  union  between 
the  tooth  and  the  alveolar  process,  thus  preventing  stretching 
of  the  fibers.  At  the  upper  border,  under  the  gum  tissue,  these 
fibers  extend  over  the  edge  of  the  alveolar  border  and  unite 
with  the  fibers  of  the  periosteum  on  the  outer  border  of  the 
process,  forming  the  interstitial  tissue. 

If  absorption  of  the  inorganic  substance  of  the  alveolar 
process  occurs,  the  fibrous  tissue  retains  the  shape  of  the  proc- 
ess. The  same  results  when  inflammation  of  the  peridental 
membrane  takes  place  at  the  gum  margin  or  at  the  apex  of  the 
root  of  the  tooth.  What  was  once  alveolar  process  is  now  peri- 
dental membrane  or  fibrous  tissue. 

Two  kinds  of  structures  are  present  in  the  alveolar  process 
— a  dense,  compact,  hard  structure  (composed  of  lime  salts), 


'  Anatomy. 

*  American  System  of  Dentistry,  page  668. 


X  75.     A.  A.  obj.     Zeiss.     Micro-pbotograplis,  reduced  one-third. 

Fig.  16. — Cross  Section  of  Tooth,  Alveolar  Process  and  Peridental  Membrane. 
Ir  jECTED  Blood  Vessels.     Normal.    Dog. 

B,  Dentine.     C,  Cementum.     I,  Peridental  Membrane.     J,  Alveolar  Process.     K, 
Capillaries.    L,  Haversian  Canals. 


X  75.     A.  A.  obj.     Zeiss.     Micro-pliotographs,  reduced  one-third. 

Fig.  17. — Cross  Section  of  Tooth,  Alveolar  Process  and  Peridental  Membrane. 
Injected  Blood  Vessels.     Normal.    Dog. 

B,  Dentine.     C,  Cementum.     I,  Peridental  Membrane.     J,  Alveolar  Process.     K, 
Capillaries.     L,  Haversian  Canals. 


GUMS  AND  MUCOUS  MEMBRANE.  49 

and  a  fibrous  tissue;  either  alone  will  retain  the  shape  of  the 
tissue. 

Blood  vessels  permeate  this  membrane  throughout  from  the 
gum  tissue  at  the  neck  of  the  tooth,  through  the  alveolar  walls 
to  the  end  of  the  roots.  They  are  most  abundant  in  youth. 
Capillary  blood  vessels  enter  the  Haversian  canals  through  the 
process  and  into  the  cementum.  Many  of  these  blood  vessels 
extend  the  entire  length  from  the  gum  margin  to  the  apex  in 
straight  lines  and  vice  versa.  In  many  of  the  illustrations,  the 
blood  vessels  will  be  seen  to  follow  the  line  of  the  alveolar 
process  (Fig.  14).  A  great  supply  of  blood  vessels  penetrate 
the  membrane  through  the  alveolar  walls.  These  vessels  unite 
and  anastomose  with  the  arteries  which  traverse  lengthwise, 
forming  a  complicated  plexus  (Fig.  16).  According  to  some 
writers  the  vascular  supply  of  the  peridental  membrane  is  situ- 
ated in  the  center  of  the  structure.  This  has  not  been  my  expe- 
rience. All  of  my  slides,  as  well  as  those  here  presented,  show 
the  blood  vessels  to  be  situated  nearest  the  alveolar  process.  It 
is  quite  natural  that  this  should  be  so,  since  very  little  blood  is 
required  for  the  nourishment  of  the  cementum,  while  the  larg- 
est amount  is  required  to  supply  the  alveolar  process.  The  sys- 
tem of  blood  vessels  situated  in  the  peridental  membrane  and 
showing  their  relation  to  the  surrounding  tissue  is  well  shown 
in  the  injected  specimen  from  healthy  dogs  (Figs.  16  and  17). 
Pus  pockets  and  abscesses  are  hence  more  liable  to  form  near 
and  in  the  alveolar  process  than  near  the  tooth  structure.  When 
infection  takes  place,  the  products  of  inflammation  are  carried 
through  the  blood  vessel  and  the  foci  of  round  cell  inflammation 
are  located  near  or  in  the  alveolar  process  where  abscesses  form. 
The  vessels  seen  in  the  membrane  anastomose  very  freely  with 
those  at  the  gum  margin,  showing  the  membrane  to  be  well 
nourished  in  all  its  parts.  Should  one  part  become  involved  by 
disease  the  other  parts  are  overnourished  in  consequence. 

These  blood  vessels  enter  the  alveolar  walls  ^\ith  the  fibrous 
tissue  through  the  Haversian  canals  and  these  in  turn  permeate 
the  entire  bone.  As  age  advances,  however,  the  bone  becomes 
more  dense,  and  the  Haversian  canals  become  smaller  and 
(under  certain  conditions)  cease  to  exist.    When  disease  takes 


50  INTEESTITIAL    GINGIVITIS. 

place,  either  at  the  gingivus  or  at  the  apex  of  the  root,  the  sup- 
ply of  hlood  being  thus  cut  off,  the  tissues  receive  sufficient 
nourishment  through  the  alveolar  wall.  Since  the  structures  are 
in  a  transitory  state,  being  destroyed  and  repaired  so  fre- 
quently, it  is  evident  why  the  blood  supply  is  so  rich. 

CALCOSPHERITES. 

Small,  hard  bodies  are  frequently  found  in  the  peridental 
membrane.  These  are  sometimes  in  the  form  of  concentric 
rings  of  lime  salts  and  are  called  calcospherites.  They  are  not 
always  round,  but  may  be  of  any  shape  and  vary  as  well  in  size. 
They  bear  the  same  relation  to  the  peridental  membrane  that 
pulp  stones  do  to  the  dental  pulp.  Black^  says:  "I  have  seen 
more  of  them  about  the  roots  of  the  molars  than  elsewhere, 
but  have  found  them  along  the  sides  of  the  roots  of  the  bicus- 
pids."  When  irritation  and  inflammation  take  place  in  the 
peridental  membrane,  the  cementol)lasts  build  up  cement  sub- 
stance, just  as  the  osteoblasts  do  in  the  alveolar  process  and 
the  odontoblasts  do  in  the  pulp  chamber.  Sometimes  they  are 
attached  to  the  root  of  tlie  tooth,  producing  a  condition  called 
exostosis  or  cementosis.  They  may  remain  unattached,  float- 
ing in  the  tibrous  tissue.  These  are  very  common  in  connec- 
tion with  interstitial  gingivitis. 

DO  GLANDS  EXIST  IN  THE  MUCOUS  AND  PERIDENTAL  MEMBRANES? 

A  somewhat  widespread  opinion  locates  special  glands  in 
the  gingival  tissues  and  the  peridental  membrane.  This  seems, 
to  a  certain  extent,  to  be  in  part  due  to  the  lack  of  definite 
knowledge  as  to  the  etiology  of  interstitial  gingivitis,  and  in 
part  to  the  fact  that  certain  constitutional  conditions,  such  as 
mercurial  and  potassium  iodid  poisoning  and  scurvy,  manifest 
themselves  in  the  gum  tissue  in  a  way  similarly  to  their  action 
in  the  glandular  structures  of  the  body.  Black*^  claims,  for  ex- 
ample: ''That  part  of  the  gingival  margin  that  lies  in  against 
the  neck  to  the  tooth  is  of  a  different  structure  from  its  other 


"  Periosteum  and  Perirleiital  Membrane,  page  94. 
^  American  System  of  Dentistry,  pages  955-956. 


X  75.     A.  A.  obj.     Zeiss.     Micro-photographs,  reduced  one-third. 

Fig.  18. — Longitudinal  Section  of  Gum.     Normal  Tissue.     Sheep. 

C,  Cementum.  E,  Epithelial  Tissue.  G,  Submucous  Membrane.  K,  Capillaries. 
M,  Fibrous  Tissue.  AA,  Point  of  Union  of  Epithelial  Tissue  and  Peridental  Mem- 
brane.    Nm,  Nasmyth's  Membrane.     Sg,  So-called  Glands  of  Serres. 


52  INTEKSTITIAL    GINGIVITIS. 

parts.  Here  it  is  clothed  with  a  very  soft,  round  or  polygonal 
gland-like  epithelium  that  suggests  the  formation  of  a  gland, 
but  fails  to  assume  the  glandular  structure,  though  it  seems  to 
have  been  regarded  as  such  by  Serres.  This — which  I  shall  call 
the  gingival  organ — emits  a  profusion  of  small  rounded  cells 
which  are  always  found  in  the  saliva  (Salter)  and  are  usually 
called  mucous  corpuscles.  It  is  well  known  that  certain  glands 
have  the  power  of  the  selection  and  excretion  of  certain  poi- 
sons, and  in  this  way  of  eliminating  them  from  the  system,  and 
that  if  the  substance  be  in  large  amount,  hyperemia,  or  even 
inflammation,  may  result.  It  is  also  known  that  mercury  and 
potassium  iodid  will  produce  inflammation  of  the  free  margins 
of  the  gums,  and  Salter  has  found  these  cells  are  in  greater 
abundance  under  these  circumstances;  also  that  the  cells  taken 
from  the  gingival  border  and  submitted  to  chemical  tests  after 
the  person  has  taken  potassium  iodid  are  found  to  yield  and 
are  tinged  with  iodin." 

Longitudinal  sections  of  the  tooth,  alveolus  and  surrounding 
tissues,  under  the  microscope,  exhibit  a  very  peculiar  formation 
of  the  mucous  membrane  at  its  line  of  union  mth  the  peridental 
membrane  at  the  neck  of  the  tooth.  Black^  (in  an  article  beau- 
tifully illustrated  by  Frederick  Noyes)  seems  to  identify  these 
with  the  so-called  glands  of  Serres  or  gingival  glands  (Fig.  18). 
He  speaks  of  them  as  glands  in  various  places  throughout  the 
article;  for  example,  ''But  little  can  now  be  said  of  the  func- 
tion of  the  network  of  glands  of  the  peridental  membrane,  be- 
yond what  is  indicated  by  their  form,  location  and  histological 
characters.  With  the  knowledge  of  their  position  and  general 
character,  clinical  observation  leads  to  the  conclusion  that  they 
are  readily  disturbed  by  certain  drugs,  notably  by  mercury  and 
iodin;  and  that  they  are  often  disturbed  by  substances  poison- 
ous to  them  floating  in  the  blood  streams.  This  is  evidenced 
by  the  appearance  of  marginal  gingivitis,  with  soreness  of  the 
peridental  membrane.  Such  disturbances  would  not  be  likely 
to  occur  without  the  presence  of  some  specialized  or  secretory 
tissue.     ...     It  seems  to  me  verv  certain  that  the  disease 


^Dental  Cosmos,  Fehniary,  1899. 


GUMS  AND  MUCOUS  MEMBRANE.  53 

which  I  have  described  as  phagedenic  pericementitis  has  its 
seat  in  these  glands."  Black,  however,  does  not  seem  quite  cer- 
tain of  the  validity  of  his  position,  since  he  further  remarks, 
''Though  definitely  lobulated,  this  body  does  not  seem  to  pos- 
sess the  characters  of  a  gland,  and  I  should  not  suppose  from 
an  examination  of  its  tissues  that  it  had  a  glandular  function. 
It  encircles  but  a  portion  of  the  neck  of  the  tooth,  usually  only 
the  approximal  portion,  thinning  away  toward  the  buccal  and 
lingual,  so  that  in  many  of  the  lengthwise  sections  it  may  be 
very  small,  or  does  not  appear  at  all." 

In  many  slides  of  sections  from  canine  jaws  and  human,^  the 
same  peculiar  arrangement  of  structure  was  observed,  although 
not  in  so  marked  a  degree.  In  the  immature  herbivora  (calf  and 
lamb)  these  peculiar  formations  of  structure  are  well  marked, 
albeit  less  so  in  the  carnivora,  and  still  less  in  man. 

Were  glands  present  in  this  locality  it  is  logical  to  infer  that 
they  would  become  involved  in  mercurialism,  plumbism  and 
scurvy,  and  exhibit  marked  inflammation  with  broken-down 
structures  in  a  given  locality,  as  at  the  union  of  the  gum  tissue 
with  the  peridental  membrane.     Such  a  case  is  unknown. 

The  mucous  membrane  under  the  microscope  appears  at  a 
point  between  the  teeth  (and  faintly  so  at  the  inner  and  outer 
border  as  shown  by  Black)  to  double  upon  itself.  When  the 
tooth  erupts,  absorption  of  the  gums  occurs  at  the  highest  point. 
The  gum  tissue  passing  down  to  the  neck  of  the  tooth  folds  or 
crowds  upon  itself  between  the  teeth  with  a  peculiar  curve 
downward,  inward  and  then  outward  and  upward.  At  the  upper 
border,  about  midway  from  the  gingival  margin  to  the  neck  of 
the  tooth,  may  be  seen  a  space  or  pocket  (never  twice  alike  in 
appearance)  where  the  edge  of  the  gum  tissue  comes  in  contact 
with  the  original  epithelium.  Sometimes  the  space  or  pocket  is 
closed  up  (Figs.  48,  49,  57).  Again  it  remains  open  (Figs.  13, 
37,  56,  59).  Frequently  this  peculiar  type  of  structure  is  absent, 
showing  that  the  fold  of  gum  tissue  either  has  been  absorbed  in 


*  The  material  obtained  for  making  slides  from  man,  other  than  the  scur\'y  cases, 
was  obtained  through  the  kindness  of  surgeons  from  jaws  removed  from  hospital 
patients,  as  a  result  of  disease;  the  surgeons  placing  them  into  alcohol  or  Miiller's 
solution  as  soon  as  removed. 


■^*p 


\:h^ 


W. 


%• 


X  75.     A.  A.  obj.     Zeiss.     Alicro-pbotugraphs,  ru<luecd  one-third. 


D 


Fig.  19.    Cross  Section  of  Tooth  and  Peridental  Membrane. 
Normal  Tissue.    Sheep. 
C,  Cementum.    D,  Dentine.    I,  Peridental  Membrane.    W,  Epithelial  Debris 


I 


I 


3*^ 


.?-' 


V. 


•;• 


X  300.    No.  2  projection  ocular.    D.  D.  obj.    Zeiss.  Micro-photographs, 
reduced  one-third. 

Fig.  20. — Cross  Section  of  Tooth  and  Peridental  Membrane. 
Normal  Tissue.    Sheep. 

C,  Cementuni.     D,  Dentine.     I,  Peridental  Membrane.     W,  Epithelial  Debris. 


56 


INTERSTITIAL    GINGIVITIS. 


the  eruption  of  the  tooth  or  did  not  form.  This  peculiar  form 
encircles  only  a  portion  of  the  neck  of  the  tooth  (according  to 
Black's  examination  of  the  structure  in  sheep).  This  in  itself 
seems  to  offset  the  glandular  theory,  since  gingivitis  almost  in- 
variably starts  on  tlie  lingual  or  palatine  and  labial  surfaces 


X  560.     No.  2  projector  ocular.     One-twelfth  obj.     Zeiss. 

Fig.  21. — Cross  Section  of  Tooth  and  Peridental  Membrane. 
Normal  Tissue.    Sheep. 

C,  Cementum.    D,  Dentine.    I,  Peridental  Membrane.    W,  Epithelial  Debris. 

where  this  structure  does  not  appear.  In  the  slides  of  the  scurvy 
case  there  does  not  appear  the  slightest  evidence  of  anything 
resembling  glandular  structure.  Hence  it  would  seem  safe  to 
conclude  that  the  glandular  structure  does  not  occur  in  this 


GUMS  AND  MUCOUS  MEMBEANE.  57 

locality.  It  is  by  no  means  impossible  that  in  the  peculiar  epi- 
thelium in  this  locaUty,  epithelial  cells  undergo  changes  which 
to  some  observers  simulate  glandular  structure,  but  on  histo- 
logic analysis  are  distinguishable  from  it,  resembling  in  this 
the  crypts  of  the  head  of  the  penis. 

In  cross  sections  of  the  peridental  membrane,  with  a  low 
power  may  be  seen  dark  bodies  arranged  along  the  margin  of 
the  cementum  in  the  peridental  membrane  (Fig.  19).  They  are 
more  numerous,  however,  near  the  gingival  border  than  at  the 
root  extremity.  These  bodies  are  more  numerous  and  better 
defined  in  the  sheep  than  in  the  calf,  and  more  apparent  in  the 
canine  jaw  than  in  the  human.  Under  higher  power  (Fig.  20) 
they  may  be  distinctly  demarcated  as  epithelial  cells  arranged 
in  single  rows  of  loops,  again  in  double  rows,  again  in  rows  of 
three  and  sometimes  in  round  or  oblong  groups,  with  clusters  of 
cells  without  shape  or  form.  With  a  still  higher  magnifying 
power  (Fig.  21)  it  will  be  seen  that  these  masses  of  cells  are 
polygonous,  never  prismatic.  They  hence  are  similar  in  shape 
to  the  epithelial  cells  situated  above  the  columnar  colls.  They 
also  resemble  the  cells  which  are  situated  inside  of  the  epithelial 
lamina.  In  the  larger  amplification  the  nucleus  can  be  readily 
observed. 

Black®  has  attempted  to  demonstrate  that  glands  exist  in 
the  structure  and  that  the  cells  last  mentioned  are  glands. 
Black  lays  down  as  a  sine  qua  non  of  a  gland  that  there  should 
be  an  opening  to  the  surface.  He  has  made  an  attempt  (Fig.  15) 
to  demonstrate  such  an  outlet,  but  this  figure  does  not  show 
clearly  that  the  glands  empty  into  the  duct  or  have  an  exit  at 
the  surface.  These  bodies,  however,  not  only  fail  (like  the 
ductless  glands)  in  this  particular,  but  in  more  important  char- 
acteristics of  glands.  They  do  not  have  (as  Robin  and  Magitot 
remark)  a  columnar  or  prismatic  cell  wall.  It  is  not  difficult 
to  understand  how  epithelial  cells  are  scattered  in  different 
shapes  and  sizes  throughout  the  peridental  membrane.     Epi- 


» Dental  Cosmos,  February,  1899,  pages  112-118. 
1"  Dental  Follicle,  page  116. 
"  Embryology,  pages  581-90. 


58  INTERSTITIAL    GINGIVITIS. 

thelial  cells  have  the  property  of  multiplying  and  developing 
in  structures  wherever  located." 

If  epithelial  cells  should  migrate  within  the  submucous  mem- 
brane and  fibrous  tissue,  proliferation  will  occur  under  certain 
circumstances.  The  tooth,  according  to  Minot,"  is  a  papilla 
which  projects  into  the  epidermis  and,  ossifying  (calcifying)  in 
a  particular  way,  changes  into  ivory  around  the  soft  core  or 
pulp;  to  the  papilla  the  epidermis  adds  a  layer  of  enamel.  The 
tooth  proper  unites  with  a  small  plate  of  dermal  bones  at  its 
base.  By  a  modification  in  the  jaws  the  epidermis  first  growls 
into  the  dermis  and  then  the  dermal  tooth  papilla  is  developed. 
The  first  indication  of  the  development  of  tooth  germs  in  mam- 
mals is  a  thickening  of  the  epithelium  covering  the  jaw.  This 
thickening,  which  appears  as  a  ridge  during  the  sixth  week  of 
embryonic  life,  forms  on  the  under  side  of  the  epithelium.  This 
curving  ridge  expands  into  an  outer  portion  (the  outline  of  the 
groove  between  the  lip  and  the  gum)  and  an  inner  portion, 
the  dental  shelf  which  grows  obliquely  inward.  The  papillae 
for  the  milk  teeth  are  formed  on  the  under  side  of  the  shelf,  and 
it  is  thus  possible  for  the  shelf  to  continue  growing  toward  the 
lingual  side,  so  that  the  second  set  of  germs  is  developed  for 
the  permanent  teeth.  The  end  of  the  shelf,  toward  the  articula- 
tion of  the  jaws,  is  prolonged  without  retaining  the  direct  con- 
nection with  the  epithelium  and  from  this  prolongation  arise 
the  enamel  organs  for  the  three  permanent  molars.  Wherever 
a  tooth-germ  arises  the  dental  shelf  is  locally  enlarged,  and  the 
local  enlargement  constitutes  an  enamel  organ  which  projects 
from  the  under  side  of  the  shelf.  The  portions  of  the  shelf 
between  the  enamel  organs  gradually  break  up,  forming  first 
an  irregular  network,  and  later  separate  fragments^-  which 
may  persist  throughout  life  and  lead  to  various  pathological 
structures.  While  the  permanent  germs  are  forming,  the  shelf  is 
solid  between  them,  although  it  has  assumed  the  reticulate 
structure  between  the  germs  of  the  milk  teeth.  In  consequence 
of  the  reticular  formation,  the  fully  developed  enamel  organs 


"  Including  the  epithelial  debris  of  Eobin  and  Magitot. 


GUMS  AND  MUCOUS  MEMBRANE.  59 

have  several  bands  or  threads  by  which  they  are  connected  with 
the  dental  shelf  proper. 

After  the  shelf  has  developed  somew^hat,  its  line  of  connec- 
tion with  the  epithelium  of  the  gum  becomes  marked  by  a  super- 
ficial groove,  as  may  been  seen  in  the  human  embryo  of  eight 
to  ten  weeks.  This  groove  was  formerly  supposed  to  be  the 
first  trace  of  the  dental  shelf,  but  Rose's  observations  correct 
the  supposition. 

The  second  step  in  mammals  is  the  formation  of  outgrowths 
(in  man  ten  in  each  jaw)  from  the  under  side  of  the  dental  shelf ; 
each  outgrowth  is  the  outline  of  an  enamel  organ  for  a  milk 
tooth.  The  outgrowth  is  covered  toward  the  mesoderm  by  a 
layer  of  the  epidermis,  w^hile  the  core  is  filled  with  polygonal 
cells  which  resemble  those  of  the  middle  part  of  the  Malpighian 
layer  of  the  skin.  The  outgrowths,  after  penetrating  a  short 
distance,  expand  at  the  low^er  ends,  but  remain  each  connected 
by  a  narrow  neck  with  the  overlying  epidermis.  The  expanded 
end  is  the  enamel  germ  proper;  it  very  soon  assumes  a  tri- 
angular outline,  as  seen  in  sections,  owing  to  the  flattening  of 
its  under  side,  and  at  the  same  time  it  moves  somewhat  toward 
the  lips.  Meanwhile  the  shelf  continues  growing  on  the  lingual 
side  of  each  ingrowth  to  produce  the  enamel  organs  destined  for 
the  second  or  permanent  teeth. 

At  this  stage  it  is  noticed  that  the  mesenchyma  under  the 
flattened  end  of  the  enamel  organ  has  become  more  dense,  to 
form  the  outline  of  the  dental  papilla,  and  is  beginning  to  de- 
velop fibrillae  around  both  the  enamel  germ  and  the  papillary 
outline.    The  fibrillar  envelope  is  the  future  dental  follicle. 

The  third  step  is  a  final  differentiation  of  the  enamel  organ 
and  the  accompanying  shaping  of  the  papilla.  The  enamel  organ 
continues  growing  and  becomes  concave  on  its  under  side  so 
that  the  mesoderm  underneath  acquires  the  shape  of  the  papilla. 
It  is  now  that  the  form  of  the  tooth  is  determined  by  the  form 
assumed  by  the  papilla,  which  in  its  turn  is  probably  deter- 
mined by  the  growth  of  the  enamel  organ. 

The  follicle  is  merely  an  envelope  of  connective  tissue  in 
which  can  be  distinguished  an  outer  dense  and  inner  looser 
layer;  in  the  latter  the  cells  are  more  distinct  and  the  fibrillar 


60  INTERSTITIAL    GINGIVITIS. 

are  less  numerous  than  in  the  former.  A  rich  network  of  capil- 
lary vessels  is  developed  in  the  follicle  and  appears  in  part  as  a 
series  of  villous-like  growth  into  the  enamel  organ.  The  folli- 
cle develops  first  over  the  lower  part  of  the  papilla,  then  over 
the  enamel  organ,  the  neck  of  which  aborts  and  the  follicle 
closes  over,  completely  separating  the  enamel  organ  from  its 
parent  epidermis.    The  enamel  organ  changes  greatly  in  appear- 


FiG.  22. — Section  through  the  Incisive  Portion  or  the  Lower  Jaw  of  an  Ovine 
Embryo,  Measuring  82  Millim.  (3  1/3  Inches)  in  Length.  Magnified  260 
DiAM.,  after  Drs.  Ch.  Legros  and  E.  Magitot. 

D,  Oral  Epithelium.  C,  Lowest  Layer  of  Cells  in  the  Stratum  Malpighii.  F, 
Epithelial  Cord.  K,  Bourgeon  of  the  Secondary  Cord.  I,  Follicular  Wall.  H,  Dental 
Bulb. 

ance.  The  layer  of  cylinder  cells  is  well  preserved  over  the 
concave  surface,  but  only  where  the  epithelium  is  in  contact 
with  the  dental  papilla.  In  the  neck  the  cells  become  irregular 
in  form.  Over  the  convex  surface  the  cells  become  lower  and 
cuboidal.  They  ultimately  atrophy  and  flatten  out.  The  cells  in 
the  center  of  the  enamel  organs  undergo  a  peculiar  metamor- 
phosis. They  remain  united  together  by  a  few  thread-like 
processes. 

It  is  obvious  from  these  changes  in  the  embryo  how  what 
Robin  calls  the  epithelial  debris  is  derived  from  the  epithelial 


GUMS  AND  MUCOUS  MEMBRANE, 


61 


cord,  the  follicular  wall  and  the  round  bodies  of  lamina  epithe- 
lium debris.  According  to  Ch.  Robin  and  Magitot/^  who  were 
the  first  to  describe  these  bodies,  "The  phenomena  of  budding 
commences,  namely,  when  the  epithelial  cord  has  finished  its 
course,  having  conducted  the  primary  enamel  organ  to  that  point 
whence  its  subsequent  evolution  will  be  effected  and  soon  after 
the  formation  of  the  secondary  follicle,  immediately  after  the 
rupture  of  the  cord  of  the  primitive  follicle."  Robin  leans  to 
the  opinion  that  these  bodies  disappear  soon  after  they  are 
formed,  "The  time  of  their  disappearance  varies,  they  remark, 
in   different   species   of  animals.     In   the   human   embryo   the 


:Mu,^?^?;^?9^  ?p:tr^:v.      K. 


Fig.  23. — Vertical  Transverse  Section  through  the  Incisive  Eeqion  of  the 
Lower  Jaw  op  Human  Foetus  Measuring  38  Centimetres  (15^^  Inches), 
Magnified  80  Diam.,  after  Drs.  Ch.  Legros  and  E.  Magitot. 

b,  Bony  Formation,  d,  Oral  Epithelium,  g,  Enamel  Organs.  H,  Dental  Bulb. 
I,  Cord  of  the  Permanent  Follicle.  K,  Debris  on  the  Follicular  Wall  of  the  Primitive 
Follicle  and  from  its  Cord.  K,  Epithelial  Globule.  L,  Enamel  Organ  of  the  Permanent 
Tooth. 


remains  of  the  cord  of  the  primitive  follicles  may  be  found,  even 
after  the  formation  of  the  follicles  of  the  permanent  teeth,  and 
it  is  probably  during  the  process  of  eruption  that  these  bud- 
dings become  atrophied;  in  the  canine  embryo  the  facts  are 
nearly  the  same;  in  the  bovine  and  ovine  embryos  (calf  and 
lamb)  it  has  seemed  to  us  that  these  proliferations  disappear  at 


"  See  their  Memoir  on  the  Genesis  and  Development  of  the  Dental  Follicle  in  Jour, 
de  Physiologic  de  Brown-Sequard,  1860. 


62  INTERSTITIAL    GINGIVITIS. 

a  correspondingly  earlier  stage ;  and  we  think  it  safe  to  say  that, 
as  a  general  rule,  the  complete  absorption  occurs  toward  the 
period  of  eruption. ' ' 

The  embryology  of  the  dental  shelf,  which  has  been  sum- 
marized by  Minot  from  Waldeyer,  Kolliker,  Von  Ebner"  and 
0.  Hertwig,  indicates  the  source  of  the  structures  which  have 
been  mistaken  by  Black  for  the  limiting  walls  of  glands. 

After  the  epithelial  cords  of  the  temporary  and  permanent 
sets  of  teeth  have  been  demarcated  from  their  folUcles,  the  proc- 


asxcrnxivv 


Fjg.  24. — From  the  Lower  Jaw  of  an  Ovine  Embryo,  Magnified  80  Diameters, 
Showing  the  Completed  Dental  Follicle  and  the  Surrounding   Tissues, 

AFTER  DrS.  Ch.  LeGROS  AND  E.   MaGITOT. 

a,  Meckel's  Cartilage,     b,  Traces  of  Ossification,     c,  Lowest  Layer  of  Epithelial 

Cells,  d,  Oral  Epithelium.  F,  Ameloblastic  Layer.  F,  (Lower)  External  Layer  of 
the  Enamel  Organ — a  continuation  of  the  Layer  of  Ameloblasts.  g,  Stellate  reticu- 
lum of  the  Enamel  Organ.  H,  Bulb.  I,  Follicular  Wall.  K,  Buddings  from  the 
Cord. 

ess  of  cell  building  proceeds  like  the  process  of  cord  building. 
These  buds,  according  to  Charles  Robin  and  Magitot,''  are  given 
off  at  tlie  upper  border  of  the  follicle  and  below  the  epithelium 
of  the  gum.  "In  fact,  as  soon  as  the  epithelial  lamina  loses  its 
connection  with  the  foUicle,  by  the  rupture  of  the  cord,  the  epi- 


"Handbuch  der  Zahnheilkunde,  1890,  pages  209-262. 
«Loc.  cit.,  1860. 


GUMS  AND  MUCOUS  MEMBRANE. 


63 


thelial  cells  composing  it  become  greatly  increased  in  number  at 
the  severed  point.  The  multiplication  of  cell-elements  results 
in  the  formation  of  irregular  buddings,  which  wander  in  differ- 
ent directions  into  the  deeper  portions  of  the  embryonal  tissue. 
These  buddings  vary  greatly  in  form ;  sometimes  they  are  sim- 
ple cylinders,  retaining  their  connection  with  the  primitive 
lamina  by  pedicles  of  various  lengths,  and  sometimes  this  slight 


X  50.     One-half -in.  obj.     No,  Oc. 

Fig.  25. — Cross  Section  of  Epithelial  Cord.    Man. 

T,  Peridental  Membrane.     W,  Epithelial  Debris  or  Cord.     EO,  Endarteritis  Obliterans. 

connection  is  absorbed,  thus  isolating  an  epithelial  mass." 

This  budding  occurs  at  different  points  along  the  cord  (Fig. 
22)  at  the  end  and  upon  the  outer  surface  of  the  follicular  wall 
(Figs.  23  and  24)  at  the  point  where  the  cord  is  severed  from  the 
enamel  organ.  These  gradually  diminish  as  they  descend  upon 
its  sides.    Doubtless  the  epithelial  cord  remains  in  the  periosteal 


64  INTEESTITIAL    GINGIVITIS. 

and  submucous  tissue  tliroughout  life.  Fig.  25  represents  evi- 
dent sections  of  epithelial  cord  in  a  man  sixty-eight  years  of  age, 
and  Fig.  26  in  a  dog  eight  years.  In  the  photographs  of  the 
scurvy  cases  and  of  dogs  will  be  seen  evidences  of  the  persist- 
ence of  epithelial  debris  late  in  life.  The  position  already  cited 
from  Eobin  and  Magitot  as  to  its  early  disappearance  would 
hence  appear  to  be  too  strongly  taken. 

Robin  and  Magitot  claim  that  this  budding  process  occurs  at 
or  about  the  time  of  the  rupture  of  the  cord.  Up  to  this  period 
ossification  has  not  taken  place,  but  then  deposits  of  bone  appear 
in  the  fibrous  tissue  of  the  middle  and  outer  surfaces.  The  bone 
deposit  gradually  takes  the  form  of  the  jaw,  filling  in  and 
encroaching  upon  the  fibrous  tissue,  forming  a  bony  wall  on  the 
one  hand,  and  the  crown  and  root  of  the  tooth  on  the  other. 
When  the  tooth  is  ready  to  erupt,  the  crown  pushes  the  soft  tis- 
sue laterally,  while  the  root  develops,  forms  a  defined  wall  with 
the  peridental  membrane  between  them.  The  epithelial  debris 
(to  use  their  term)  which  before  was  scattered  over  the  entire 
surface  of  the  dental  follicle,  is  now  crowded  into  the  very  nar- 
row space  of  the  peridental  membrane,  and  owing  to  the  position 
of  the  debris  at  the  upper  part  of  the  follicle,  it  would  be  nat- 
ural to  find  most  of  it  at  the  peridental  membrane. 

BONE    BUILDING   AND   ABSORPTION. 

Development  of  the  alveolar  process  is  relegated  to  a  series 
of  cells  situated  in  the  fibers  of  the  peridental  membrane  or 
fibrous  tissue,  and  close  to  the  margin  of  the  bone  tissue,  and 
throughout  the  Haversian  canals.  These  cells  are  called  the 
osteoblasts.  They  perform  the  function  of  building  up  the  bone 
tissue.  Even  after  the  alveolar  process  has  developed  its  normal 
shape,  so  unstable  is  the  nervous  system  which  presides  over 
these  cells  at  this  locality,  that  at  the  slightest  provocation, 
either  local  or  constitutional,  they  will  continue  their  process  of 
construction.  Hence,  the  frequency  of  hypertrophy  of  the  proc- 
ess, and  in  disease  the  calcification  of  the  peridental  membrane. 

On  the  other  side  of  the  membrane,  next  the  root  surfaces, 
may  be  seen  other  cells  which  build  up  and  destroy  the  cemen- 


BONE  BUILDING'  AND  ABSORPTION, 


65 


tiiin;  these  are  called  cementoblasts  and  cementoclasts.  These 
are  of  little  importance  in  this  connection  with  the  study  of  this 
disease,  although  they  are  frequently  present  and  at  work  when 
inflammation  of  the  membrane  occurs. 

There  is,  however,  another  class  of  cells  found  in  the  peri- 


X  560.     No.  2  projection  ocular.     One-twelfth  obj.     Zeiss. 

Fig.  26. — Cross  Section  Epithelial  Cord.     Dog. 

I,  Peridental  Membrane.     W,  Epithelial  Debris  or  Cord.     U,  Nerve  Tissue. 

dental  membrane  of  the  utmost  importance  in  this  connection, 
the  osteoclasts,  located  in  the  fibers,  and  in  close  proximity  to 
the  alveolar  wall,  and  around  the  inner  border  of  the  Haversian 
canals.     The  function  of  these  cells  is  to  tear  down  irregular 


66  INTERSTITIAL    GINGIVITIS. 

bone  and  tootli  strncture  due  to  unstable  nervous  tissue,  and 
from  tlie  slightest  irritation. 

The  gums,  mucous  membrane,  alveolar  process  and  peri- 
dental membrane,  owing  to  their  transient  nature,  are  influenced 
by  the  slightest  irritation.  This  influence  is  the  result  of  both 
constitutional  and  local  causes.  It  consists  of  an  irritation  in 
the  peripheral  nerves  which  sets  the  osteoblasts  and  osteoclasts 
at  work  to  l)uild  up  or  tear  down  the  alveolar  process.  This  in- 
fluence may  be  only  sufficient  to  stinuilate  these  cells  to  action 
without  inflammation.  This  is  noticed  in  the  advance  toward  old 
age,  in  long,  lingering  debility,  in  the  development  of  bone,  espe- 
cially the  tearing  down  and  the  building  up  of  the  inferior  max- 
illary backward.  It  may  be  noted  in  mild  or  intense  inflamma- 
tion of  the  peridental  membrane,  due  to  more  acute  forms  of 
disease,  to  scurvy,  mercurial,  lead  and  iodide  poisoning,  or  to 
local  irritation.  So  sensitive  are  these  structures  that  in  neu- 
rotics and  degenerates  the  slightest  irritation  produced  in  the 
physiologic  development  of  the  permanent  teeth  is  sufficient  to 
start  the  osteoblasts  to  building  up  bone  structure,  thus  pro- 
ducing that  pathologic  condition  called  hypertrophy  of  the  alve- 
olar process ;  one  of  the  most  marked  evidences  of  an  unstable 
nervous  system. 

The  breaking  down  of  the  tissues  by  the  osteoclasts  may  be 
induced  by  as  slight  a  cause.  The  alveolar  process  being  so  thin 
about  the  teeth,  destruction  of  the  entire  walls  is  accomplished 
without  difficulty,  and  in  a  very  short  time,  thus  loosening  the 
teeth,  which  eventually  drop  out. 

According  to  Kaufmann  ^'''  the  following  processes  take  part 
in  the  absorption  of  bone :  (a)  Lacunar  Absorption,  (b)  Forma- 
tion of  Perforating  Canals,  (c)  Disappearance  after  Prior 
Absorption  of  Lime  (Halisteresis)  (Bony  Waste)  and  Osteo- 
malacia. 

"By  far  the  connnonest  form  of  bone  destruction  is  by 
lacunar  absorption.  This  process  occurs  not  only  under  physio- 
logic conditions,  but  is  extraordinarily  frequent  in  pathologic 
states,  e.  g.,  in  the  various  types  of  atrophy.    They  form  on  the 


"Pathologische  Anatomie. 


BONE  BUILDING  AND  ABSORPTION, 


67 


smooth,  superficial  surfaces  of  the  bone  deep  grooves  (so-called 
Howship's  lacunae)  in  which  lie  smaller  or  greater  polynuclear 
cells  (osteoclasts,  Kolliker)  which  evidently  blend  together  (Fig. 
27).  There  are  no  alterations  of  the  bone  substance  that  would 
indicate  a  primary  line  of  absorption  (Plummer).  The  con- 
fluence of  these  lacunae  form  larger  cavities. 

''The  second  form  of  bone  absorption,  which  is  occasionally 
met  under  physiologic  conditions,  is  by  means  of  perforating 
canals  (so-called  Volkmann  canals).  Under  physiologic  condi- 
tions canals  occur  in  varying  numbers  in  tlie  lamellae  (general 


Fig.  27. 

a,  Bone  Trabeevila'.     h,  Tubercle  with  Granulation  Tissue,    c.  Broken-down  Tissue. 

d,  Blood  Vessel,     e,  Osteoclasts.    /,  Fat  Cells.  (Kaufmann.) 

lamellae)  which  contain  vessels  (perforating  vessels).  These  are 
often  associated  with  the  Haversian  canals  and  gradually  pass 
into  them,  but  unlike  them,  are  surrounded  with  circular  lam- 
ellae. Under  pathologic  conditions  the  conception  of  these  per- 
forating canals  is  somewhat  widened.  On  the  one  hand 
Volkmann 's  canals  are  spoken  of  when  reference  is  made  to  the 
vessels  or  vascular  connective  tissue  penetrating  from  one 
medullary  space  in  the  spongy  substance,  or  from  one  Haversian 
canal  in  the  compact  substance,  to  another,  in  such  a  way  that  a 
passage  is  made  from  one  part  of  the  bone  to  the  other;  Volk- 


68 


INTERSTITIAL    GINGIVITIS. 


mann's  canals  also  include  irregular  ampula-formed  dilations 
or  cavities  (Fig.  28).  By  confluence  of  these  are  produced  cav- 
ities or  irregularly  outlined  canals  penetrating  tlie  bone  sub- 
stance. These,  if  they  empty  into  the  medullary  space,  become 
filled  witli  cells. 


I 


e  b    a  e  ^ 


Fig.  28. 

a,  Large  Spaces  Eesulting  from  Absorption  of  the  Trabeculse.  h,  Decalcified  Bone. 
c  and  d,  Decalcified  Bone  and  Atrophied  Trabecular,  c,  Haversian  Canals.  (Kauf- 
mann.) 

"Under  much  rarer  conditions,  especially  in  senile  marasmic 
osteomalacia  and  also  in  that  occurring  in  pregnancy,  bone 
absorption  takes  place  after  a  prior  abstraction  of  lime  (haliste- 
resis)  and  the  remaining  substance  (bone  cartilage)  is  then  fur- 


BONE  BUILDING  AND  ABSORPTION.  69 

tlier  dissoh^ed,  passing  through  a  temporary  fibroid  stage.  This 
destruction  of  the  decalcified  and  interfibrillae  decomposed  bone 
is  produced  as  a  rule  without  osteoclasts.  The  decalcified  border 
zones  of  the  trabeculse  appear  with  simple  carmine  (coloring)  or 
by  double  stains. ' ' 

Viewing  the  alveolar  process,  including  the  gums,  peridental 
membrane  and  periosteum  in  man's  ontogeny  as  a  whole,  it  will 
be  seen  that  the  changes  which  are  going  on  in  apparently  nor- 
mal individuals  make  it  an  exceedingly  transitory  structure. 

In  connection  with  what  has  already  been  said  in  regard  to 
the  transitory  nature  of  the  alveolar  process,  there  is  another 
factor  to  be  considered  which  makes  it  a  doubly  transitory 
structure. 

In  man's  phylogeny,  in  some  of  the  lower  vertebrates  ^'^  there 
is  a  continuous  succession  of  teeth  throughout  life.  In  man's 
ontogeny,  it  would  be  strange  if  he  did  not  retain  still  further 
evidences  of  phylogenetic  peculiarities  in  tooth  development  in 
relation  to  the  alveolar  process. 

Man  and  some  of  the  lower  vertebrates  have  only  two  sets  of 
teeth.  When  the  first  set  comes  into  place,  the  alveolar  process 
builds  itself  up  about  the  roots  to  hold  the  teeth  in  place.  When 
these  are  to  be  lost,  a  low  form  of  inflammation  sets  up  absorp- 
tion of  the  bone  and  the  teeth  are  lost.  When  the  second  set 
erupt  new  bone  is  developed  about  the  roots  to  hold  the  second 
set  in  place.  Should  man  live  long  enough  the  second  set  would 
drop  out  even  though  he  possessed  a  normal  healthy  body. 
This  process  is  atavistic.  With  all  these  changes  going  on  in 
man's  ontogeny,  we  again  have  an  exceedingly  transitory  struc- 
ture. With  the  phylogenetic  and  ontogenetic  changes,  man  has 
a  doubly  transitory  structure  in  the  alveolar  process.  I  have 
called  this  process  of  bone  absorption,  osteomalacia  or  juvenile 
or  senile  absorption  according  to  the  age  of  the  patient.^® 

Transitory  structures  are  more  easily  involved  in  disease 
than  other  structures.  How  much  more  quickly  then  will  a 
structure  which  is  doubly  transitory  become  involved  in  disease? 


"Talbot.     Developmental  Pathology:   A  Study  in  Degenerative  Evolution. 
"  Talbot.     Pathogeny   of   Osteomalacia  or  Senile   Atrophy.     The  Dental   Digest, 
August,  1903. 


70  INTERSTITIAL    GINGI\'ITIS. 

Mammals  (upon  whom  researches  have  been  conducted  by  the 
author)  demonstrate  they  are  phylogenetically  subject  to  this 
disease  and  perhaps  lower  vertebrates,  including  the  reptiles 
under  similar  circumstances  or  environment., 

The  Al\teolae  Process  as  an  End  Organ/''- — I  have  called  the 
alveolar  process  an  end  organ.  My  reason  for  doing  this  is  that 
the  tooth,  so  far  as  the  process  and  its  diseases  are  concerned,  is 
a  foreign  body.-°  The  arteries,  vessels  of  Von  Ebner  and  espe- 
cially the  nerves  pass  through  the  bony  process,  in  a  wavy  man- 
ner and  stop  at  the  root  of  the  tooth. 

There  are  other  end  organs  in  the  body,  chief  of  which  are 
the  kidneys,  the  eye  and  the  brain.  Physicians  claim,  and 
rightly,  that  because  these  are  end  organs  they  are  more  easily 
involved  in  disease  and  are  often  the  determining  factors  of 
kidney  lesions.  Alfred  C.  Croftan  says,  "It  is  not  surprising 
to  find  that  particularly  those  organs  that  are  supplied  by  end 
arteries  are  chiefly  involved,  for  in  them  vascular  disturbances 
must  first  produce  nutritional  derangement.  Chief  among  the 
organs  supplied  by  end  arteries  are,  precisely,  the  kidneys,  the 
retina  and  the  brain,  and  I  think  this  explains  the  frequent  in- 
volvement of  the  kidneys,  eyes  and  brain  in  Bright 's  disease. 
The  fact  that  the  retina  and  the  brain  are  often  found  injured 
before  the  kidneys,  that  cases  of  Bright 's  disease  run  their  fatal 
course  occasionally  with  practically  no  renal  changes,  but  with 
serious  apoplectiform  brain  lesions  and  retinitis,  bears  out  this 
conception  and  constitutes  a  valid  argument  against  the  com- 
mon belief  that  the  nephritis  is  the  primary  event  and  the  de- 
termining phenomenon  of  the  disease." 

A  marked  difference  exists  between  the  kidney,  eye  and  brain 
as  end  organs  and  the  alveolar  process  as  an  end  organ.  This 
difference  is  the  important  point  in  the  study  of  interstitial  gin- 
givitis. End  arteries  running  into  the  kidney,  eye  and  brain, 
owing  to  the  soft  nature  of  these  tissues,  are  given  a  chance  to 
expand  and  recover,  permitting,  in  a  measure,  the  blood  to  flow 
more  easily,  thus  prolonging  the  tendency  to  disease,  or  allow- 


"  Endarteritis  Obliterans.     The  Dental  Digest,  October,  1903. 

^''  Interstitial    Gingivitis    or   So-called   Pyorrhoea    Alveolaris.      The    Dental    Sum- 
mary, 19t)3. 


ALVEOLAR  PROCESS  AS  AN  END  ORGAN.  71 

ing  the  tissues,  under  favorable  conditions  to  recover.  On  the 
other  hand,  blood  vessels  extending  throughout  the  alveolar 
process  in  a  tortuous  manner  cannot  expand,  and  as  a  result, 
blood  charged  with  toxins  and  subject  to  cardio-vascular  changes 
immediately  sets  up  irritation  and  inflammation  which  results  in 
dilatation,  bone  absorption  and  arterial  degeneration.  These 
changes,  therefore,  will  occur  much  earlier  in  the  alveolar  proc- 
ess than  in  other  end  organs. 

The  transitory  nature  of  the  alveolar  process,  especially  as 
an  end  organ,  makes  it  exceedingly  sensitive  to  systemic 
changes  and  disease.  The  sensitiveness  of  this  structure  to  auto- 
toxic  states  is  easily  demonstrated  as  people  advance  in  years. 
At  the  fifth  period  of  stress  (about  forty-five  and  beyond)  the 
excretory  organs  weaken.  The  toxic  elements  of  the  body  are 
not  carried  off  as  freely  as  formerly.  These  circulate  in  the 
blood  and  accumulate  in  the  alveolar  process,  setting  up  irrita- 
tion and  inflammation.  Absorption  of  the  alveolar  process  grad- 
ually takes  place.  People  enjoying  apparently  good  health  -will, 
as  they  advance  in  years,  note  the  absorption  of  the  alveolar 
process  and  the  exposure  of  the  roots  of  the  teeth.  How  much 
more  readily  will  absorption  take  place  when  the  function  of 
any  one  of  the  eliminating  organs  be  involved,  such  as  constipa- 
tion, asthma,  skin  affections  or  kidney  lesions. 

In  addition  to  the  alveolar  process  being  a  doubly  transitory 
structure  it  is  also  an  end  organ,  of  a  bony  nature  and  the  most 
sensitive  structure  of  the  human  organism,  hence  any  constitu- 
tional disturbance  due  to  disease,  drug  poisoning  or  autointoxi- 
cation would  more  quickly  affect  it.  Sudden  changes  in  temper- 
ature from  heat  to  cold  and  vice  versa,  where  the  organism  is 
unable  to  adjust  itself  readily,  also  leave  their  mark  upon  the 
very  susceptible  tissue. 

The  study  of  interstitial  gingivitis  and  its  treatment  must  be 
based  upon  the  phylogeny,  ontogeny  and  peculiar  anatomy  of 
the  structures  involved.  There  are  no  other  structures  in  the 
human  body  associated  like  the  jaws,  alveolar  process  and  teeth. 
The  pathology,  therefore,  is  unique  in  itself. 

Transitory  structures  in  the  body  as  well  as  end  organs  are 
known  to  be  very  susceptible  to  disease  and  are,  as  a  rule,  the 


72  INTERSTITIAL    GINGIVITIS. 

first  to  be  involved.  The  alveolar  process,  being  classed  as  a 
doubly  transitory  structure  as  well  as  an  end  organ  consisting 
of  bone,  is  one  of  the  first,  if  not  the  first,  structure  to  register 
systemic  changes. 


CHAPTER  VIL 

INOEGAXIC  SALTS  AXD  INTERSTITIAL  GIXOn^ITIS. 

The  foods  wliicli  enable  the  body  to  repair  its  waste,  to  bnikl 
up  new  tissue  and  to  supply  the  energy,  are  divisible  into  four 
classes :  the  inorganic  substances,  the  fats  or  hydrocarbons, 
and  the  starches  and  sugars,  or  carbohydrates,  and  the  proteid 
compounds.  These  divisions  are,  however,  relative,  since  the 
proteids  may  contain  both  hydrocarbons  and  carbohydrates. 
The  inorganic  substances,  such  as  water,  phosphates,  chlorides, 
carbonates,  sulphates,  etc.,  enter  the  body,  as  a  rule,  under  their 
own  form,  either  alone  or  in  combination  with  other  classes. 
They  are  not  oxidized  or  split  up  within  the  system  to  enter  into 
the  chemical  formations  of  other  compounds,  but  are  united 
mechanically  with  the  proteid  group.  These  bodies  act,  as  a  rule, 
in  a  purely  mechanical  manner.  After  ha\dng  served  their  pur- 
pose, they  pass  out  of  the  system  with  the  excretions,  compara- 
tively unchanged  in  their  composition.  They  are  the  only 
member  of  the  group  of  foods  which  are  of  a  special  interest  in 
the  present  research.  The  inorganic  salts  have  not  received  the 
attention  from  physiologic  chemists  that  their  importance  de- 
mands. They  are,  as  a  rule,  found  in  greater  or  lesser  quanti- 
ties in  all  foods  taken  into  the  body.  They  do  not  serve  as  a 
source  of  energy,  but  as  the  other  foods  are  needed  for  the  de- 
velopment of  the  tissues,  so  the  inorganic  salts  are  needed  for 
the  building  of  bone  tissue  and  the  repair  of  waste.  This  is  ac- 
complished b}^  the  soluble  salts  in  the  blood.  Human  blood  has 
the  follo"s^dng  composition : 

ANALYSIS   OF   HUMAN   BLOOD    (c.   SCHMIDT).      HOWELL 's   PHYSIOLOGY. 

Man.  Woman. 

25  Years.  30  Years. 

Water 788.71  ....  82-4.55 

SoHds    211.29  ....  175.45 

Proteids  and  Extractives 191.78  ....  157.93 

Fibrin 3.93  ....  1.91 

Hfematin  (and  iron) 7.70  6.99 

Salts   7.88  ....  8.62 


74  INTERSTITIAL    GINGIVITIS. 

INORGANIC  SALTS  OF  HUMAN   BLOOD,   1,000  PARTS    (c.   SCHMIDT). 

Blood  Corpuscles. 
Blood  Plasma. 

CI   1.75  CI   3.53G 

K,o   3.091  K20   0.311 

NA.,    0.470  NA.o    3.410 

SO3'    O.OGl  SO3    r 0.129 

P205    1-355  P.O.    0-145 

CaO    CaO    

^'^no    ^'^90    

These  acids  and  bases  exist,  of  course,  in  the  plasma  and  the 
corpuscles  as  salts.  It  is  not  possible  to  determine  exactly  how 
they  are  combined  as  salts,  but  Schmidt  suggests  the  following 
combination : 

PROBABLE  SALTS  IN  THE  CORPUSCLE. 

Potassium  Sulphate   0.132 

Potassium  Chloride    3.679 

Potassium  Phosphate 2.343 

Sodium  Phospate   0.633 

Sodium  Car])ouate   0.341 

Calcium  Phosphate    0.094 

Magnesium  Plio_sphate    0.060 

PROBABLE  SALTS  IN  THE  PLASMA. 

Potassium  Sulphate   0.281 

Potassium  Chloride    0.359 

Sodium  Chloride 5.546 

Sodium  Phosphate   0.271 

Sodium  Carbonate   1.532 

Calcium  Phosphate    0.298 

Magnesium  Phosphate    0.218 

It  will  be  seen  that  the  corpuscle  contains  an  excess  of 
potassium  salts,  and  the  plasma  contains  an  excess  of  sodium 
salts.    All  parts  of  the  blood  contain  salts,  however. 

Throughout  the  entire  body,  there  is  a  rich  supply  of  blood 
vessels  penetrating  every  tissue.  The  plasma  of  the  blood  pass- 
ing by  exosmosis  through  the  walls  of  the  capillaries  is  thus 
brought  in  immediate  contact  with  the  tissues  to  which  it  brings 
nourishment  and  oxygen  of  the  blood,  and  from  which  it 
removes  the  waste  products  of  metabolism.  Other  usable  prod- 
ucts or  lymph  are  collected  in  small  capillary  spaces,  which  in 


INORGANIC  SALTS  AND  INTERSTITIAL  GINGIVITIS.  iO 

turn  open  into  definite  lymphatic  vessels.  These  vessels  unite 
into  larger  and  larger  ones,  which  eventually  pour  this  usable 
waste  product  into  the  great  thoracic  or  left  lymphatic  ducts,  and 
a  second  smaller  right  lymphatic  duct.  These  in  turn  empty 
into  blood  vessels,  each  upon  its  own  side.  The  lymph  contains 
essentially  the  same  constituents  as  the  blood  plasma,  and  the 
salts  are  found  in  the  same  proportion  as  in  it.  They  are  then 
eliminated  through  the  sweat  glands,  tonsils,  mucous  glands, 
kidneys,  large  intestines  and  salivary  glands. 

The  composition  of  the  deposits  in  the  various  parts  of  the 
body  vary  according  to  the  locality  and  the  character  of  the 
excreta  eliminated  in  connection  vdth  them. 

The  chemical  composition  of  the  human  bile,  according  to 
Jacobson,^  is  as  follows : 

Water  977 .40 

Sodium  Glyeoeholato 9 .  94 

Cholesteriii    0.54 

Free  Fat 0.10 

Sodium  pahnitate  and  sterrate 1.26 

Lecitine    0 .  04 

Other  organic  matter  2.26 

Sodium  chloride 5.45 

Potassium  chloride 0 .  28 

Sodium  phosphate  1-33 

Lime  phosphate   0.37 

Sodium  carbonate   0 .  93 

Of  this  analysis  the  solid  ingredients  constitute  22.5  parts  per 
thousand,  of  which  two-thirds  are  organic  and  one-third  inor- 
ganic. The  inorganic  salts  of  the  bile  are  in  most  cases  returned 
to  the  blood,  where  they  are  redistributed  to  the  tissues.  Occa- 
sionally, however,  gall  stones  occur,  which  are  composed  of 
(analysis  H.  D.  Geddings  -) : 

Moisture    3 .  32 

Biliary  matter   32 .  182 

Cholesterin    54.952 

Matter  soluble  in  ether 7.77 

Iron traces 

Phosphoric  acid     traces 

Lime    traces 

Magnesium   traces 

^  American  System  of  Dentistry. 

"  Transactions  South  Carolina  Medical  Association,  1880. 


76  INTERSTITIAL    GINGIVITIS. 

Secretions  of  tlie  pancreatic  juice  (dog)  by  C.  Schmidt  are  as 
follows : 

Water 900.76 

Solids    99 .  24 

Organic    substances    90 .  44 

Ash   8 .  80 

Sodium  carbonate   0 .  58 

Sodium  chloride 7 .  35 

Calcium  magnesium  and  sodium  phosphate 0.53 

The  composition  of  the  normal  human  pancreatic  juice  has 
not  been  determined  completely  owing  to  the  difficulty  of  obtain- 
ing the  secretion.  According  to  Zawadsky  the  composition  of 
the  secretion  of  a  young  woman  was  as  follows : 

Water  in  1,000  parts 864.05 

Organic  substance  in  1,000  parts 132.51 

Proteids    in  1,000  parts 92 .  05 

Salts    in  1,000  parts 3 .  44 

INORGANIC  SALTS  IN  THE  SWEAT. 

''Of  the  inorganic  salts,  NaCl  is  by  far  the  most  abundant; 
it  occurs  in  quantities  varjdng  from  2  to  3.5  parts  per  thousand. 
The  elements  of  the  sweat  which  are  of  importance  from  an 
excretory  standpoint  are  water,  inorganic  salts  and  urea  or  re- 
lated nitrogenous  compounds, ' ' 

Inorganic  salts  from  the  faeces  are  made  up  of  the  salts  of 
sodium,  potassium,  calcium,  magnesium  and  iron.  According  to 
Enderlin  ^  the  following  represent  the  composition  of  the  ma- 
terial matter  in  the  faeces : 

S.A.LTS   SOLUBLE   IN   WATER. 

Sodium  phosphate  2 .  63 

Sodium  chloride  and  sulphate 1.37 

S.\LTS  INSOLUBLE  IN  WATER. 

Earth  phosphate    80 .  37 

Ferric  phosphate   2 .  09 

Calcium  sulphate 4.53 

Silicic  acid  7.94 

Like  other  constituents  of  the  lymph,  the  salts  vary  consider- 
ably in  proportion,  according  as  the  fluid  is  more  or  less  rich  in 

"Gamgee,  Physiological  Chemistry  of  the  Animal  Body. 
*  American  Text-Book  of  Physiology. 


INORGANIC  SALTS  AND  INTERSTITIAL  GINGIVITIS.  i  I 

water.     The  salts  are  much  more  abundant  than  the  organic 
sohds. 

Inorganic  salts  in  the  urine  consist,  according  to  Howell,* 
chiefly  of  chlorides,  phosphates  and  sulphates  of  the  alkalies  and 
the  alkaline  earths.  As  a  rule  they  arise  partly  from  the  salts 
ingested  with  the  food,  which  salts  are  eliminated  from  the  blood 
by  the  kidney  in  the  water  secretion,  and  in  part  they  are  formed 
in  the  destructive  metabolism  which  takes  place  in  the  body, 
particularly  that  involving  the  proteids.  Sodium  chloride  occurs 
in  the  largest  quantities  (about  15  grams  per  day),  of  which  the 
greater  part  is  derived  directly  from  the  salt  taken  in  the  food. 
The  phosphates  occur  in  combination  with  Ga  and  Mg,  but  chiefly 
as  acid  phosphates,  of  Na  or  K,  The  acid  reaction  of  the  urine 
is  caused  by  these  latter.  The  phosphates  are  produced  in  part 
from  destruction  of  phosphorous-containing  tissues  in  the  body, 
but  chiefly  proceed  from  phosphates  in  the  food.  Following  are 
the  average  quantities  in  grams  of  the  chief  substances  normally 
excreted  in  the  urine  in  six  hours : ' 

Water    1440      —  1500 

Sohds    57     —  68 

Organic : 

Urea    28     —  68 

Uric  acid   7 

Hippuric  acid  3      —  2 

Kreatinin    1.7-^—  2.1 

Inorganic : 

Sodium   chloride    15      —  20 

Phosphoric  acid 2.5  —  3 

Sulphuric  acid    2      —  2.5 

Sodium  5      —  7 

IMagnesium    .04 

Potassium    3      —  4 

Calcium    .03 

Urinary  calculi  (classified  according  to  their  principal  ingre- 
dients), are  divided  into: 

1.  Uric  stone,  composed  of  uric  acid  and  acid  urates. 

2.  Oxalic  stone,  composed  of  lime  oxalate. 

3.  Phosphoric  stone,  which  are  composed  of  magnesium 
phosphate  and  carbonate  with  urate  of  ammonia. 


•  Landolt,  Physiology. 


78  INTERSTITIAL    GINGIVITIS. 

Each  oiie  of  these  compounds  is  nearly  in  a  pure  state.  A 
stone  may  be  composed  entirely  of  one  salt  or  it  may  be  com- 
posed of  two,  three  or  four,  each  compound  forming  separate 
consecutive  layers  through  the  stone.  One  examination  made  by 
Howship  Dickinson  '^  showed  eighty-nine  per  cent  lime  carbonate 
and  the  rest  lime  oxalate  and  phosphate  of  lime. 

The  deposits  upon  the  teeth  are  derived  partly  from  the  salts 
ingested  with  foods,  which  salts  are  eliminated  from  the  blood  in 
water  secretion,  and  in  part  they  are  found  in  the  waste  of  tissue 
which  takes  place  in  the  body. 

The  saliva,  according  to  Schmidt,  is  made  up  of  the  following: 

Water 991.45 

Organic  material  2 .  89 

Inorganic : 

Calcic  chloride  4 .  50 

Sodium  chloride •  •  •  -^ 

Calcic  phosphate   1-16 

Magnesium    •  •  •  • 

1,000.00 

This  material  floating  in  the  saliva,  together  with  the  epithe- 
lial scales  and  other  extraneous  matters,  contribute  to  form  what 
is  known  as  tartar.  This  material  collects  upon  the  teeth,  and 
according  to  examinations  by  Stevenson  consists  of : 

Soft  tartar  Hard  tartar 

on  molars.         on  lower  incisors. 

Water  and  organic  matter 21.48  17.51 

Magnesium  phosphate    1.31  1.31 

Calcium   phosphate   with   a   litte   carbon- 
ate and  trace  of  flourine 77.21  81.18 

100.00  100.00 

Another  analysis  made  by  Scheheoetskey  resulted  thus  : 

Water  and  organic  matter 22.07 

Magnesium  phosphate    1.07 

Calcium  phosphate    67 .  18 

Calcium  carbonate 8 .  13 

Calcium  flouride    1 .  55 


100.00 


•  Renal  and  Urinary  Affections. 


INORGANIC  SALTS  AND  INTERSTITIAL  GINGIVITIS. 


79 


Malenfant  found  that  salivary  calculi  (located  in  Wharton's 
duet)  was  composed  of: 

Lime  phosphate   27 

Magnesium  phosphate    1 

Basic  lime  phosphate   60 

Alcohol  and  muriatic  acid 4 

Ptyalin  . 2 

Loss 6 

100 

The  following  are  results  of  analysis  of  salivary  calculi  by 
various  observers : 


Calcium   carbonate 

Calcium  phosjihate 

Magnesium  phosphate. 

Soluble  solids 

Organic  matter 

Water  and  loss 


81.2 

79.4 

80.7 

13.9 

30 

15 

4.1 

5.0 

4.2 

38.2 
5.1 

75 

55 
1 

6.2 
7.1 

4.8 
8.5 

5.1 

8.3 

38.1 

5 

25 

1.3 

2.3 

1.7 

6.3 

2 
75 

23 


Deposits  in  the  tissues  in  gout  are  made  up  of  soda  and  lime 
urates.  In  order  to  compare  the  calcic  deposits  in  other  parts  of 
the  body  with  the  so-called  serumal  deposits  upon  the  teeth  af- 
fected with  interstitial  gingivitis,  thousands  of  teeth  were  ob- 
tained from  three  dental  offices  which  make  a  practice  of  extract- 
ing teeth.  From  these  one  thousand  were  selected  at  two  differ- 
ent times,  making  two  thousand  teeth  containing  deposits  direct 
from  the  tissues.  These  were  submitted  to  a  chemical  analysis 
by  J.  H.  Salisbury,  at  Rush  Medical  College,  who  reports  as 
follows : 

''The  method  which  I  employed  in  analysis  of  calcic  deposits 
was  as  follows :  The  material  was  so  selected  as  to  be  free  as 
possible  from  salivary  tartar  and  a  weighed  portion  was  dried  at 
100°  C.  This  was  then  carefully  incinerated  and  again  weighed, 
and  the  difference  calculated  as  organic  matter.  The  residue 
after  incineration  was  divided  into  two  portions,  A  and  B. 

"A  was  used  for  the  estimation  of  phosphates  as  follows: 
The  ash  was  dis&clved  in  nitric  acid  and  the  solution  precipitated 


80  INTERSTITIAL    GINGIVITIS. 

with  ammonium  molybdate.  The  precipitate  was  washed,  dis- 
solved in  ammonia  precipitated  by  magnesia  mixture  and  the 
precipitate  of  ammonia  magnesium  x)hosphate,  washed,  dried, 
ignited  and  weighed. 

"In  B,  calcium  and  magnesium  were  estimated  as  follows: 
The  ash  was  dissolved  in  hydrochloric  acid  and  the  acid  just 
neutralized  with  ammonia  water  and  sodium  acetate  added.  It 
was  then  made  slightly  acid  with  a  drop  of  hydrochloric  acid 
and  precipitated  with  ammonium  oxalate.  The  precipitate  of 
calcium  oxalate  was  filtered  off,  washed,  converted  into  calcium 
oxide  and  weighed.  The  filtrate  was  made  alkaline,  sodium 
phosphate  added,  and  the  precipitate  of  magnesium-ammonium 
phosphate  collected,  washed,  dried,  ignited  and  weighed.  In 
case  the  phosphoric  acid  determined  in  A  did  not  saturate  the 
calcium  and  magnesium  obtained  in  B,  the  excess  of  base  was 
calculated  as  carbonate. 

''The  following  is  the  composition  of  the  calcic  deposits  on 
the  roots  of  the  teeth,  according  to  analysis  of  April  18, 1898 : 

"Water  and  organic  matter 32.24 

Magnesium  phosphate    -98 

Calcium  phosphate 63 .  08 

Calcium  carbonate 3 .  70 

100.00 

''Analysis  of  the  calcic  deposits  on  the  roots  of  the  teeth 
October  24,  1898,  shows  it  to  have  the  following  composition: 

Water 4.48 

Organic  matter 27 .  00 

Calcium  phosphate 72 .  73 

Magnesium  phosphate    4. 91 

99.12 

The  composition  of  the  alveolar  process  is  as  follows : 

Organic  matter:   Gelatine  and  blood  vessels 33.30 

Inorganic  matter: 

Calcium  phosphate 51 .  04 

Calcium  carbonate 11 .  30 

Calcium  fiouride 2 .  00 

Magnesium  phosphate    1 .  10 

Sodium  oxide  and  sodium  chloride 1.26 

100.00 


INOKGANIC  SALTS  AND  IXTEESTITIAL  (ilNUlVITIS.  81 

By  comparing  the  tables  of  the  composition  of  calcic  deposits 
upon  the  roots  of  teeth  with  that  of  the  alveolar  process,  it  will 
be  observed  that  there  is  very  little  difference.  Tartar  deposited 
from  the  salivary  glands  and  calcic  deposits  upon  the  roots  of 
the  teeth  must  not  be  confounded  since  there  is  little  in  common 
between  them,  Tartar  is  the  principal  cause  of  local  interstitial 
gingivitis  commencing  at  the  gum  margin,  while  calcic  deposits 
are  the  result  of  interstitial  gingivitis  and  are  always  located 
upon  the  root  of  the  tooth  at  the  point  of  absorption  of  the 
alveolar  process.  The  amount  of  calcic  salts  in  the  blood  is  very 
small  as  compared  with  the  amount  deposited  upon  the  roots  of 
the  teeth  and  what  is  lost  in  the  fluids  around  the  teeth.  The 
author  '  has  stated  that  the  calcic  deposit  upon  the  roots  of  the 
teeth  was  the  absorbed  alveolar  process  and  not  derived  direct 
from  the  blood  as  has  been  suggested. 

While  nearly  every  kind  of  food  taken  into  the  stomach  con- 
tains inorganic  salts,  every  excretory  organ  of  the  body  throws 
out  a  certain  amount  of  these  salts.  Some  of  these  organs 
excrete  the  salts  in  a  pure  state,  while  in  others  the  salts  are 
combined  with  acids  or  fluids  peculiar  to  that  organ.  These  salts 
differ  in  composition  and  quantity  on  different  days,  at  different 
hours  of  the  same  day;  differ  at  different  ages  of  the  same  per- 
son and  differ  in  persons  of  like  age,  on  the  same  diet.  No  mat- 
ter how  careful  the  chemist  may  be  in  analysis,  no  two  results 
will  be  exactly  alike.  For  this  reason,  in  tartar  and  calcic  deposit 
upon  the  roots  of  teeth,  two  different  analyses  of  the  same  de- 
posits are  cited.  It  is  evident  that  while  slight  differences  occur 
in  the  table,  these  are  due  chiefly  to  the  character  of  the  secre- 
tions. The  kidneys  and  salivary  glands  clearly  excrete  most  of 
the  waste  inorganic  salts. 

Since  each  excretory  organ  has  its  part  in  elimination  of 
waste  inorganic  salts,  it  is  clear  that  if  one  organ  becomes  tired 
or  diseased,  other  organs  have  an  extra  amount  of  material  to 
excrete.  In  any  event,  the  blood  becomes  surcharged  with  waste 
inorganic  salts.  There  is  a  class  of  patients  with  deformed  jaws 
and  irregular  teeth,  tonsil  hypertrophy,  mucous  membrane, 
nasal  bone  and  post-nasal  space  disorder,  adenoids,  arrest  of  the 


'  Endarteritis  Obliterans.    The  Dental  Digest,  1903. 


82  INTERSTITIAL    GINGIVITIS. 

facial  bones.  They  are  neurotics  and  possess  degenerate  struc- 
tures. This  class  comprehends  those  whose  nervous  system  is 
unstable  and  whose  physical  development  is  a  departure  from 
the  race  type.  This  unstable  or  tired  condition  may  affect  but 
one  excretory  organ.  In  most  cases  it  affects  all  organs  as  well 
as  the  entire  body.  In  these  patients,  especially  in  youth,  does 
hypertrophy  of  the  alveolar  process  take  place  and  large  de- 
posits are  observed  upon  the  teeth.  In  this  class  may  be  placed 
rachitic  children. 

Inorganic  salts  taken  in  food  are  generally  utilized  until  the 
osseous  system  has  attained  its  growth.  This  usually  occurs  at 
about  the  twenty-sixth  year,  but  full  growth  may  not  be  attained 
until  the  thirty-sixth  year.  When  this  period  has  been  reached, 
although  the  body  still  has  the  sam^e  supply  of  inorganic  salts, 
the  system  can  assimilate  only  what  it  needs.  The  remainder 
becomes  waste.  Under  such  conditions  the  blood  is  overcharged 
with  these  salts. 

A  condition  of  the  system,  which  has  received  too  little  atten- 
tion, occurs  in  a  class  of  children  ranging  from  six  to  eight 
years,  who  excrete  larger  quantities  of  inorganic  salts  through 
the  kidneys  and  salivary  glands.  In  such  cases  the  teeth 
become  coated  with  tartar.  The  gums  become  inflamed  from 
irritation.  Interstitial  gingivitis  is  developed  in  youth.  These 
children  may  be  rachitic,  or  border  upon  the  disease.  They  are 
neurotics,  with  degenerate  structures,  suffer  from  rachitis,  rapid 
decay  of  the  teeth  and  irregularities.  They  occur  in  American 
and  European  schools  of  idiocy  and  for  dependent  and  defective 
children.  From  seventy-five  to  ninety  per  cent  of  these  children 
have  interstitial  gingivitis,  ranging  from  simple  inflammation  of 
the  gums  to  absorption  of  the  gums  and  alveolar  process  with 
pus  exudate.  Miller  noticed  in  an  examination  of  twenty-six 
cases  of  rachitic  children  under  twelve  years  of  age  that  seven 
manifested  pronounced  symptoms  of  interstitial  gingivitis. 
This  was  no  doubt  due  to  accumulation  of  calcic  salts  upon  the 
teeth,  producing  irritation  and  absorption  of  the  alveolar  proc- 
ess and  contraction  of  the  gums. 

In  cases  where  large  collections  of  tartar  are  deposited  upon 
the  teeth  of  children  there  is  also  an  excess  of  excreta  through 


INOEGANIC  SALTS  AND  INTERSTITIAL  GINGIVITIS.  oS 

the  kidneys.  Examination  of  urine  in  such  cases  will  reveal 
always  from  four  to  eight  times  more  deposit  than  the  normal 
for  the  age  of  the  patient.  Defective  nutrition  is  the  result,  the 
bones  are  small,  and  the  jaws  and  teeth  are  irregular.  The  teeth 
decay  early  in  life  and  it  is  with  difficulty  that  the  decay  can  be 
arrested.  What  is  true  of  children  is  also  true  of  people  at 
advanced  age. 

After  the  skeleton  had  attained  its  growth  (even  in  those 
cases  where  no  deposits  were  before  observed)  the  blood  became 
overcharged  with  lime  salts  and  the  teeth  became  a  nidus  for  the 
deposit  from  the  salivary  glands.  It  is,  therefore,  clear  why 
deposits  and  inflammation  of  the  gums  are  so  common  after  the 
twenty-sixth  year,  and  more  common  later  in  life.  Defective 
children  and  people  who  have  obtained  their  growth  are  more 
susceptible  to  trophic  disorders  of  nutrition  and  the  tissues  take 
on  disease  more  readily  than  healthy  individuals  earlier  in  life. 
When  inflammation  takes  place  in  connective  tissue  in  all  parts 
of  the  body  (especially  if  the  blood  be  surcharged  with  inorganic 
salts)  deposits  take  place  in  that  tissue  through  the  capillary 
system.  On  the  other  hand,  when  inflammation  of  the  connective 
tissue  takes  place,  if  inorganic  salts  be  scarce  in  the  blood,  de- 
posits do  not  take  place.  As  is  elsewhere  sliown,^  calcic  deposits 
on  the  roots  of  teeth  are  a  result  of  inflammation  and  pus  infec- 
tion and  not  the  cause. 


International  Dental  Journal,  April,  1896. 


CHAPTER  VIIL 

THEORIES  OF  INTERSTITIAL  GINGIVITIS. 

The  etiology  of  interstitial  gingivitis,  according  to  the  views 
summarized  previously,  is  divisible  into  local  and  constitutional. 
While  one  school  leans  largely  to  the  local  etiology,  another  ad- 
vocates as  strongly  the  constitutional  theory,  and  a  third  be- 
lieves in  both  the  constitutional  and  local  theories  as  causes. 
The  author,  from  his  elaborate  researches  which  began  in  1886, 
is  an  exponent  of  the  latter  class.  In  a  general  way,  etiology  may 
be  divided  into  exciting  and  predisposing.  Etiology  may  also 
depend  upon  an  element  dependent  on  the  exciting  cause, 
an  element  dependent  on  the  constitution  of  the  individual  at- 
tacked, and  finally  an  element  dependent  on  his  condition 
when  attacked,  both  as  regards  his  general  system  or  any  one 
of  his  organs.  The  chief  constitutional  causes  to  which  the 
disease  has  been  ascribed  are  general  conditions  of  the 
health,  heredity,  constitutional  disorders,  excessive  lime  salt 
secretion,  meat-eating,  nervous  exhaustion,  scorbutus  and  uric 
acid  states,  as  well  as  environment.  To  these  may  be  added 
drug  and  metal  poisoning  such  as  mercury,  lead,  brass, 
arsenic,  bromides,  etc.,  as  well  as  autointoxication.  The  local 
causes  assigned  are  acute  inflammation  of  the  mucous  mem- 
branes, catarrhal  states,  germs  or  fungi,  irregular  teeth, 
lactic  acid,  pocket  disease,  hemorrhagic  deposits,  serumal 
calculi  and  uncleanliness.  That  all  these  factors  exercise  an 
influence  is  undeniable,  but  the  enormous  etiologic  role  which 
has  been  assigned  to  some  of  them  is  the  result  of  generalization 
from  too  few  causes.  Many  of  the  assigned  causes  could  be  com- 
pressed into  fewer  etiologic  influences.  Thus  meat-eating,  the 
uric  acid  states,  arthritis  or  gout  are  too  intimately  connected  to 
be  regarded  as  different  causes,  from  a  constitutional  stand- 
point. As  has  been  already  pointed  out,  uric  acid  acts,  when  it 
acts  at  all,  like  lactic  and  other  acids,  as  a  local  irritant  rather 


THEORIES  OF  INTERSTITLVL  GINGIVITIS.  85 

than  as  the  constitutional  condition  (as  many  suppose)  which 
underlies  its  production  and  of  which  it  serves  as  an  index. 

Scorbutus  is  an  expression  of  a  nutritional  disorder  due  very 
frequently  in  the  adult  to  an  excess  of  meat  or  a  monotom^  of 
diet.  It  is  a  constitutional  disorder,  peculiarly  apt  to  have  its 
local  expression  in  the  gums  long  ere  the  general  constitutional 
symptoms  are  manifest.  The  germs  and  fungi  etiologists,  on  the 
other  hand,  tend  to  ignore  the  constitutional  state  behind  the 
local  culture  medium,  which  must  be  furnished  before  growth  of 
the  germ  or  fungus  can  occur.  In  order,  therefore,  to  determine 
whether  an  alleged  cause  be  exciting  or  predisposing  and  what 
is  the  influence  of  the  etiologic  moment,  as  the  union  at  one  time 
of  the  two  constitutional  factors  already  cited  is  called,  analysis 
is  required  of  all  the  varied  factors  charged  with  producing  the 
disease.  The  influence  of  heredity  is  generally  left  out  of  con- 
sideration unless  it  be  direct,  which  it  rarely  is,  since  heredity, 
as  has  been  well  remarked,  is  usually  a  prophecy  rather  than  a 
destiny.    It  hence  constitutes,  as  a  rule,  a  predisposition. 

The  chief  tissues  concerned  in  the  elimination  of  waste  prod- 
ucts are  the  skin,  the  lungs  and  air  passages,  including  the 
mouth  and  nose,  the  kidneys,  liver  and  intestines.  Interference 
with  the  eliminatory  powers  of  the  kidneys,  liver  and  intestines 
causes  autointoxication  and  is  especially  apt  to  throw  extra  work 
on  the  skin,  lungs  and  air  passages.  Of  this  a  sour-winey  odor 
of  the  breath  in  diabetes  is  an  excellent  illustration.  What  is 
true  of  such  a  marked  form  of  suboxidation,  resulting  in  auto- 
intoxication, is  true  of  less  pronounced  forms.  The  peculiarly 
foul  odor  of  the  breath  and  skin  in  faecal  intoxication  indicates 
that  the  mucous  membranes  of  the  nose,  throat,  mouth  and  gums 
are  doing  the  work  of  elimination  which  should  have  been  done 
by  the  intestines.  The  failure  of  the  kidney  to  perform  its  share 
of  eliminatory  work  is  most  apt,  however,  to  find  expression  in 
the  skin,  lungs,  nose,  mouth  and  gums. 

The  influence  of  the  nervous  system  on  the  growth  and 
repair  of  any  tissue  is  admitted  by  every  physiologist.  This 
influence  is  entitled  the  trophic  function  of  nerves.  It  is  not, 
however,  exactly  settled  whether  it  be  exerted  through  the 
nerves  themselves  or  secondarily  through  their  control  of  the 


86  INTERSTITIAL    GINGIVITIS. 

vaso-motor  (blood  vessel)  system.  Many  trophic  distnrbances, 
as  J.  Collins  ^  remarks,  are  probably  due  to  vaso-motor  changes, 
and  it  is  not  possible  to  separate  by  any  sharply  defined  line  the 
vaso-motor  from  the  tropho-neuroses.  At  the  same  time,  it 
should  be  distinctly  remembered  that  there  exist  tropho-neuroses 
in  which  there  are  no  apxjreciable  vaso-motor  changes  as  in  many 
cases  of  acromegaly  and  hypertrophies.  On  the  other  hand, 
there  are  any  amount  of  vaso-motor  disturbance  which  are  by 
no  means  trophic  in  character.  Trophic  disturbance,  which  may 
play  a  very  important  part  at  the  onset  of  interstitial  gingivitis, 
is  neurotic  cedema  due  to  nerve  irritation.  While  this  is  most 
frequent  on  the  face,  lips,  tongue,  pharynx,  forehead  and  genital 
organs,  it  also  appears  on  the  gums.  The  cedema  reaches  its  full 
development  in  from  one-half  to  two  hours.  There  is  a  feeling 
of  stiffness  and  unyieldingness,  but  no  sensation  of  inflammatory 
swelling.  This  type  of  trophic  disorder  often  initiates  changes 
in  the  mucous  membrane  which  may  readily  form  the  basis  of 
interstitial  gingivitis.  This  condition  may  not  be  only  due  to 
ordinary  nervous  causes,  but  may  arise  from  constitutional  con- 
ditions, gout,  etc.,  and  toxic  influences. 

*  Nervous  Diseases,  by  Dr.  F.  X.  Dercum. 


CHAPTER  IX. 

URIC    ACID   AND    INTERSTITIAL    GINGIVITIS. 

Uric  acid  was  first  isolated  by  Sclieele  in  1776.  It  consists  of 
a  white  spongy  powder.  It  is  devoid  of  taste  and  odor.  Under 
the  microscope  it  is  seen  as  rhombic  tables  or  as  elongated  plates 
resembling  sheaves  or  rozettes.  As  deposited  in  the  urine,  it  has 
a  more  or  less  reddish  tinge  due  to  the  presence  of  urinary  color- 
ing matter. 

The  nitrogenous  constituents  of  urinary  excretion  consist 
chiefly  of  urea  or  uric  acid  in  certain  animals  and  other  nitro- 
genous urinary  constituents.^ 

Uric  acid  is  found  abundanth^  in  the  urine  of  the  lower  ver- 
tebrates, such  as  reptiles,  birds  and  mammals.  It  would  be 
strange  if  it  were  not  found  in  the  fish  tribe.  It  is  more  abun- 
dant in  birds  than  in  reptiles.  It  seems  to  be  a  normal  constit- 
uent in  both.  Uric  acid  occurs  more  frequently  in  the  urine  of 
carniverous  mammals,  although  frequently  absent.  While  found 
in  the  urine  of  the  herbivora,  the  quantity  is  often  small  and 
variable.  Traces  of  uric  acid  are  found  in  the  organs  of  these 
animals  such  as  the  brain,  heart,  lungs,  spleen,  pancreas,  while 
it  is  always  found  in  the  blood  of  birds.  In  birds,  the  uric  acid 
is  partly  formed  from  the  purin  bases.  It  would  be  strange, 
tlierefore,  if  it  did  not  develop  in  man  since  he  has  retained 
many  of  the  phylogenetic  peculiarities  of  his  precursors.  In 
human  urine,  uric  acid  is  observed  in  variable  amounts.  It  has 
been  observed  in  healthy  human  blood.  According  to  Hammar- 
sten,^  the  amount  of  uric  acid  eliminated  with  human  urine  varies 
considerable  but  amounts  on  an  average  to  0.7  grams  per  day. 

Hammarsten  says,  ''We  used  to  ascribe  an  increasing  action 
upon  the  elimination  of  uric  acid  to  proteid  food,  but  the  investi- 
gations of  Hirschfeld,  Rosenfeld  and  Orgler,  Silven,  Burian  and 
Schur  and  others  have  positively  proven  that  a  diet  rich  in  pro- 


^  Hammarsten,  Physiological  Chemistry,  page  485. 


88  INTERSTITIAL    GINGIVITIS. 

teid  does  not  itself  increase  the  elimination  of  uric  acid  but  only 
according  to  the  amount  of  nucleins  or  purin  bodies  contained 
therein.  The  common  statement  that  the  elimination  of  uric  acid 
is  smaller  with  a  vegetable  diet  than  with  an  animal  diet,  when 
the  quantity  may  be  two  grams  or  more  per  twenty-four  hours, 
is  explained  by  this."  We  would  naturally  expect  to  find  uric 
acid  in  patients  who  live  on  a  strictly  vegetable  diet  as  well  as 
in  those  who  live  on  a  meat  diet,  since  uric  acid  is  found  in  herbi- 
vora  as  well  as  carnivora. 

The  uric  acid,  in  so  far  as  it  is  produced  from  nuclein  bases, 
is,  in  part,  derived  from  the  nucleins  of  the  destroyed  cells  of  the 
body  and  in  part  from  the  nucleins  of  free  purin  bases  intro- 
duced with  the  food. 

Belonging  to  the  same  group  as  uric  acid  are  hypoxanthin, 
xanthin,  guanin  and  adenin.  These  are  called  purin  bodies  and 
are  liberated  during  the  digestion  of  nucleo-proteids  contained 
in  food.  It  has  been  found  that  a  diet  of  meat,  especially  veal, 
liver,  pancreas  and  sweetbreads  containing  a  large  amount  of 
nucleo-proteid,  leads  to  an  increase  in  the  excretion  of  purin 
bodies  in  the  urine  as  compared  with  a  diet  of  eggs,  butter,  milk, 
fruit,  vegetables,  cheese  and  bread.  The  amount  of  uric  acid  ex- 
creted in  new  born  infants  is  in  excess  as  compared  with  the 
adult. 

The  morbid  conditions,  in  which  the  uric  acid  passed  in  the 
urine  is  increased,  are  leucocytosis  and  leukaemia.  This  increase 
may  be  attributed  to  the  degeneration  of  the  excess  of  leucocytes 
in  the  blood.  Certain  drugs  increase  the  amount  of  uric  acid, 
e.  g.,  pilocarpin  and  salicylates. 

Luxury  and  modern  degeneracy  are  generally  charged  with 
the  production  of  diseases  which  were  later  found  to  have  at- 
tacked man  in  prehistoric  periods.  This  has  been  the  case  with 
interstitial  gingivitis. 

E.  E.  Andrews  expresses  the  following  opinion  as  to  modes 
of  life:  ''I  have  been  led  to  believe  from  my  own  experience 
that  this  trouble  exists  largely  in  the  mouths  of  people  accus- 
tomed to  luxury — good  livers,  people  about  middle  age  who 
over-eat  and  under-work. ' ' 


URIC  ACID  AXD  INTERSTITIAL  CxIXOrV^ITIS.  89 

No  method  of  Ihdng  can  be  regarded  as  a  cause  of  interstitial 
gingivitis  except  so  far  as  it  affects  the  general  system,  thus 
producing  trophic  changes.  There  is  probably  a  slight  differ- 
ence in  liability  to  interstitial  gingivitis  between  people  of  seden- 
tary habits  and  active  outdoor  workers,  as  well  as  between  ani- 
mals domesticated  or  in  captivity  and  those  which  run  at  large. 

It  is,  however,  obvious  from  the  data  of  the  chapter  upon 
''History"  that  all  races  and  stations,  regardless  of  time,  cli- 
mate, or  mode  of  Hfe,  have  suffered  with  the  disease.  Examina- 
tions of  animals  in  the  American  and  European  zoological  gar- 
dens show  that  it  is  not  confined  to  any  class  of  animals.  Dogs, 
cats,  horses,  cows,  whether  housed  or  running  at  large,  suffer 
with  it  as  age  advances. 

Uric  acid  formation  is  not  confined  to  large  eaters.  Spare 
eaters  may  have  considerable  quantities  since  they  may  be  unable 
to  take  care  of  the  uric  acid  derived  from  the  moderate  amount 
of  uric  acid  forming  substances  (purin  bodies)  in  a  normal  diet. 

To  summarize  then,  it  will  be  seen  that  the  age  of  the  patient, 
the  condition,  of  his  system,  the  character  and  quantity  of  food 
eaten  and  certain  drugs  must  always  be  considered  in  relation  to 
the  quantit}^  of  uric  acid  excreted. 

Since  the  discovery  of  uric  acid  in  the  urine  by  Scheele  in 
1776,  the  alleged  influence  of  this  factor  was  steadily  advanced 
to  the  time  of  Haig,  of  London,  the  most  prominent  exponent  of 
this  theory.  Since  his  time,  a  better  knowledge  of  uric  acid  for- 
mation and  its  influence  upon  the  system  has  revealed  the  usual 
exaggeration  of  the  influence  of  this  particular  etiologic  ele- 
ment. Researches  have  shown  that  uric  acid  poisoning,  in  a 
greater  or  lesser  degree,  is  dependent  upon  the  state  of  the  sys- 
tem, the  nature  and  strength  of  the  exciting  cause.  All  three 
play  a  part  in  the  digestion,  assimilation  and  elimination  of  the 
purin  bodies  which  underlie  the  condition  of  health  formerly  at- 
tributed exclusively  to  uric  acid. 

The  uric  acid  theory  of  disease  having  been  so  strongly  advo- 
cated by  certain  physicians,  a  number  of  dentists  have  applied 
the  same  theory  as  a  cause  of  interstitial  gingivitis  and  pyor 
rhoea  alveolaris. 


90  INTERSTITIAL    GINGIVITIS. 

What  John  Fitzgerald  -  calls  the  gingival  organs,  possess,  as 
he  remarks,  in  common  with  some  other  tissues  of  the  body,  the 
power  of  selecting  and  excreting  poisonous  substances  from  the 
blood.  Some  of  these  cause  hyperaemia,  or  even  inflammation,  in 
their  passage.  Uric  acid  has  been  found  to  play  a  part  in  so 
many  excretions  that  it  has  naturally  attracted  attention  here. 
The  trend  of  medical  opinion  has  set  strongly  in  this  direction, 
but  of  late  this  trend  is  changing. 

During  the  past  two  decades  uric  acid  has  assumed  again  the 
prominence  in  pathogeny  which  it  once  had  when  called  sup- 
pressed gout.  It  is  not  surprising,  therefore,  to  find  that  Reeves, 
Pierce,  Rhein  and  others  claim  a  uric  acid  etiology  for  inter- 
stitial gingivitis.  In  support  of  this  claim  are  advanced  the 
results  of  three  experiments  which  Pierce  has  had  made  on 
tooth  deposits.  These  deposits  were  examined  chemically  by 
Ernst  Congdon,  of  the  Drexel  Institute."  The  first  specimen 
contained  a  number  of  needle  crystals  of  calcium  urate,  a  few 
crystals  of  free  uric  acid  and  crystals  of  calcium  phosphate. 
Destructive  distillation  gave  a  strong  amnionic  reaction.  The 
murexid  test  for  uric  acid  and  its  compounds  gave  faint  results, 
although  its  characteristic  color  was  evident  in  several  places. 
The  second  specimen  presented  the  same  crystals.  The  reaction 
to  the  murexid  test  was  strong  and  resulted  in  a  number  of 
purplish-red  spots.  Similar  results  were  obtained  from  the  third 
specimen.  A.  B.  Brubaker  examined  six  or  eight  specimens 
in  Pierce's  presence,  with  like  results  to  those  obtained  in  the 
previous  examination.  In  three  an  abundance  of  sodium  urate 
crystals  were  present. 

The  great  deficiency  in  the  experiments  thus  described  is  the 
small  number  of  cases  examined  and  the  lack  of  proper  control 
experiments.  These  elements  have  so  frequently  led  to  errors  in 
dental  pathology  that  I  determined  upon  a  series  of  investiga- 
tions in  two  different  laboratories,  whose  results  were  reported 
some  years  ago.*  The  Columbus  Medical  Laboratory  was  se- 
lected for  one  series  of  experiments  in  special  cases.    The  labora- 


2  The  Clinical  Journal,  March  1,  1899. 

^International  Dental  Journal,  Vol.  XV,  pages  1,  217,  501. 

*  Dental  Cosmos,  April,  1896.  page  310.     Journal  of  the  American  Medical  Asso- 
ciation, January  16,  1897. 


"URIC  ACID  AND  IXTERSTITIAL  GINGIVITIS.  91 

tory  of  tlie  Northwestern  University  Woman's  Medical  School 
was  selected  for  the  other  series  of  experiments,  to  which  teeth 
were  sent  as  soon  as  they  were  obtained.  One  hundred  and  fifteen 
teeth  VN'^ere  sent  to  the  laboratory  last  named  from  three  institu- 
tions in  Chicago  Avhicli  make  a  specialty  of  extraction.  These 
teeth  had  no  history  other  than  the  fact  that  the  cases  were  well- 
marked  instances  of  interstitial  gingivitis  with  plenty  of  calcic 
deposits,  and  that  the  teeth  were  loose  in  the  sockets  when  ex- 
tracted. Of  the  one  hundred  examinations  made  in  the  Columbus 
Medical  Laboratory,  fifty  were  upon  specimens  of  calcic  deposits 
from  my  patients  and  fifty  were  upon  specimens  obtained  from 
the  institutions  just  mentioned,  and  were  therefore  ^\ithout  his- 
tory. The  tests  employed  were  the  hydrochloric  acid,  the  dry 
distillation,  and  the  murexid,  these  being  the  tests  recommended 
by  Pierce.  The  examinations  in  the  Columbus  Medical  Labora- 
tory were  made  by  J.  A.  Wesener,  and  those  in  the  laboratory  of 
the  Xorthwestern  University  Woman's  Medical  School  by  J.  H. 
Salisbury. 

Of  the  one  hundred  and  fifteen  examinations  made  at  the 
Northwestern  University  Woman's  Medical  School  by  the  first 
test,  in  only  two  cases  were  found  the  needle-shaped  crystals, 
and  one  in  which  there  was  a  slight  resemblance  of  uric-acid 
crystals.  By  the  dry  distillation  test,  thirteen  gave  no  reaction 
from  ammonia,  and  in  seven  the  reaction  was  slight.  The  re- 
maining eighty  gave  a  decided  reaction.  By  the  murexid  test, 
four  gave  a  slight  murexid  color,  but  remainder  gave  no  reac- 
tion. Special  examinations  was  made  of  twelve  of  these  teeth  by 
the  addition  of  strong  hydrochloric  acid,  warming,  decanting  the 
acid,  and  washing  with  water.  These  gave  no  reaction  by  the 
dry  distillation  for  ammonia.  Two  gave  a  slight  reaction  by  the 
murexid  test.  Li  examination  of  the  teeth  of  three  uric-acid 
diathetic  women,  over  forty  years  of  age,  uric  acid  was  not 
detectible  either  by  the  murexid  test  or  microscopically.  The 
examinations  made  in  the  Columbus  Medical  Laboratory  were 
still  more  interesting,  since  among  them  were  specimens  from 
patients  whose  history  could  be  obtained.  Of  the  fifty  obtained 
outside,  eight  gave  positive  results  from  all  three  tests.  The 
other  forty-two  were  positive  by  dry  distillation,  and  negative  by 


92  INTERSTITIAL    GINGIVITIS. 

the  murexid  and  microscopical  tests.  Of  the  fifty  patients, 
thirty-eight  females  and  twelve  males,  thirty-two  were  over  forty 
years  of  age,  twelve  over  thirty  years,  and  six  over  fifteen  years. 
Twenty-six  have  uric  acid  to  a  greater  or  less  extent,  nine 
suffer  with  indigestion,  seven  of  which  are  subject  to  sick  head- 
ache, thirty-four  have  rheumatism.  Six  are  English,  and  four  of 
these  have  the  true  gout;  the  other  two  have  rheumatism. 

All  are  positive  with  the  dry  distillation  test.    All  are  nega- 
tive with  the  murexid  test.     Forty-nine  are  negative  with  the 
microscopical  test.     One  shows  needle-shaped  crystals,  but  not 
uric  acid.     It  is  a  singular  fact  that  in  both  laboratories,  the 
cases  in  which  there  were  uric  acid  and  gouty  histories  gave  neg- 
ative results.     By  the  dry  distillation  test,  out  of  two  hundred 
and  fifteen  cases,  all  but  twelve  cases  (which  have  been  treated 
to  remove  nitrogenous  material)  responded.    The  twelve  cases  so 
treated  did  not  respond,  since  nitrogenous  compounds  in  and 
about  teeth  (even  the  saliva)  burned  to  an  ash  will  produce 
ammonia.     By  the  murexid  test  only  twelve  out  of  the  two 
hundred  and  fifteen  gave  a  positive  reaction.     By  the  micro- 
scopic examination  but  ten  showed  crystals.  One  of  the  chemists 
who  made  the  examination  is  positive  that  they  were  uric  acid 
crystals.    The  other  is  not,  since  lime-phosphate  crystals  resem- 
ble uric  acid  crystals  too  minutely  to  be  distinguished  positively. 
For  three  years  Wesener  made  further  examinations  as  to  the 
relative  value  of  the  three  tests  employed.     According  to  his 
experiments  the  murexid  test  is  the  most  valuable,  the  crystal 
test  second,  and  the  dry  distillation  third.    The  murexid  test  is 
the  most  reliable  in  testing  tartar  for  uric  acid,  since  its  red  color 
is  easily  distinguished  from  other  colors  and  the  test  is  simple  in 
application.    The  test  for  crystallized  uric  acid  is  very  unsatis- 
factory, since  here  must  be  dealt  with  a  complex  mass  which  not 
only  contains  crystals  of  calcium  phosphate   (very  similar  to 
those  of  uric  acid)  but  a  great  mass  of  detritus  obscuring  the 
crystals  of  uric  acid.    If  crystals  be  present  they  by  no  means 
settle  the  existence  of  uric  acid.    When  the  faintest  quantity  pos- 
sible of  uric  acid  is  mixed  with  tartar  from  teeth  and  subjected 
to  crystallization,  the  results  are  always  negative.    If  subjected 


UEIC  ACID  AND  INTERSTITIAL  OIXOIVITIS.  93 

to  the  murexid  test,  the  results  are  always  positive.  The  dry 
distillation  test  is  so  inaccurate  as  to  be  unworthy  consideration. 

Since  these  results  were  published,  seven  hundred  and  thirty- 
five  cases  have  been  examined.  These  examinations  were  con- 
ducted by  Jerome  H.  Salisbury,  now  of  Eush  Medical  College. 
The  teeth  procured  from  institutions  which  make  a  specialty  of 
extracting  contained  the  dark  calcic  deposit  above  the  pus  line. 
By  the  murexid  test,  six  out  of  the  three  hundred  gave  a  distinct 
reaction;  eighteen  showed  crystals  under  the  microscope.  The 
murexid  test  was  performed  as  follows:  The  deposit  was  se- 
lected as  carefully  as  possible,  removed  from  the  tooth,  and 
placed  in  a  small  porcelain  crucible.  A  drop  of  pure  nitric  acid 
was  added  and  the  mixture  evaporated  on  the  water  bath.  When 
dry,  the  evaporation  was  repeated  with  another  drop  of  nitric 
acid,  and  the  crucible  allowed  to  cool.  When  cool,  the  color  pro- 
duced by  the  nitric  acid  was  observed,  and  then  a  glass  rod,  wet 
mtli  ammonia  water,  was  brought  near  the  deposit,  and  any  color 
produced  was  noted.  If  no  color  was  observed,  the  ammonia  was 
allowed  to  flow  over  the  residue.  A  yellow  color  was  produced 
in  many  cases  by  the  nitric  acid,  which  was  deepened  by  the 
addition  of  ammonia.  The  microscopic  examination  was  made 
by  scraping  off  the  deposit  and  evaporating  it  with  a  drop  of 
hydrochloric  acid.  The  residue  was  moistened  ^^ith  water,  and 
the  insoluble  material  placed  on  a  slide  and  covered  with  a 
cover-glass.  It  was  examined  with  a  No.  7  objective.  Uric 
acid,  therefore,  occurred  in  a  certain  very  small  proportion  of 
cases  of  calcic  deposit  on  the  teeth. 

Four  hundred  and  thirty-five  cases  w^ere  later  examined,  mak- 
ing in  all  nine  hundred  and  fifty.  Out  of  these  four  hundred 
and  thirty-five  cases  only  four  per  cent  showed  uric  acid  by  the 
murexid  test  and  eight  per  cent  by  the  crystal  test.  Since  the 
crystal  test  is  not  so  accurate  as  the  murexid  test,  it  is  safe  to  say 
that  six  per  cent  was  the  actual  per  cent  of  uric  acid.  As  a 
result  of  the  different  experiments,  in  the  first  two  hundred  and 
fifteen  cases  fi.ve  per  cent  uric  acid  was  found.  In  the  second 
three  hundred  cases,  four  per  cent,  and  in  the  third  four  hundred 
and  thirty-five  cases,  six  per  cent  w^as  found.  In  an  examination 
of  nine  hundred  and  fifty  cases  by  different  chemists  at  different 


94  INTERSTITIAL    (ilNGIVITIS. 

periods,  five  to  six  per  cent  give  positive  results  as  to  uric  acid  by 
the  cliemic  and  microscopic  examination.  These  results  demon- 
strate conclusively  that  interstitial  gingivitis  is  not  due  solely  to 
uric  acid ;  that  uric  acid  when  found  is  merely  an  expression  of 
the  uric  acid  diathesis  and  a  coincidence,  since  it  is  not  always 
present  in  the  gums  and  tartar  of  patients  attacked  either  by 
gout  or  the  uric  acid  diathesis.  In  the  six  per  cent  of  cases  there 
was  nothing  to  show  that  uric  acid  was  the  cause  of  interstitial 
gingivitis,  since  the  deposits  were  examined  after  the  teeth  had 
been  removed.  Any  other  irritation  may  have  been  the  exciting 
cause.  Uric  acid  acts,  when  at  all,  solely  as  a  local  irritant,  like 
other  acids  and  poisons.  A  microscopic  examination  of  the  tis- 
sues involved  occasionally  reveals  uric  acid  crystals.  The  fact, 
however,  that  they  are  found  in  a  small  number  of  patients  suf- 
fering with  interstitial  gingivitis  shows  that  they  cannot  be  de- 
pended upon  as  a  general  cause  of  the  disease. 


CHAPTER  X. 

HEREDITY    AND    ENVIRONMENT    IN    INTERSTITIAL    GINGIVITIS. 

The  relations  of  heredity  are  far  more  intricate  than  is  usu- 
ally assumed  to  be  the  case  in  the  average  discussion  of  the  sub- 
ject. The  problem  consequent  on  impregnation  is  not  that 
involved  in  the  mere  carrying  of  the  mixture  of  parents  in  a  fully 
developed  form  through  intra-uterine  life.  As  all  vertebrate 
organs  pass  through  the  same  stages  before  definitely  differen- 
tiating, the  later  types  have  to  gain  at  the  expense  of  the  earlier 
and  hence  must  receive  greater  energy  from  the  direct  ancestors. 
The  want  of  this  energy  is  shown  in  the  various  defects  and  de- 
partures from  types  which  occur  in  the  different  degeneracies 
and  congenital  defects.  The  types  of  heredity  ordinarily  con- 
sidered are  direct  heredity  where  the  individual  takes  after  im- 
mediate ancestry,  and  type  heredity  where  he  takes  after  the 
type  to  which  he  belongs. 

The  influence  of  heredity  in  interstitial  gingivitis,  as  in  other 
morbid  conditions,  is  still  a  mooted  question.  Morbid  heredity, 
as  I  have  elsewhere  shown,'  is  practically  divisible  into  direct 
and  indirect.  The  first  is  the  direct  inheritance  of  the  weakened 
organism  of  the  mother;  the  second  is  a  condition  of  intra-uter- 
ine infection.  Heredity  further  should  be  distinguished  from 
congenital  states  which  result  from  the  operation  of  germs  or 
toxins  during  a  particular  pregnancy  wherein  these  pass  through 
the  placenta  to  the  foetus.  A  child  may  be  born  of  a  tuberculous 
mother  with  a  tendency  to  tuberculosis  but  may  not  develop  it; 
on  the  other  hand  the  tubercle  bacilli  may  infect  it  through  the 
placenta  so  that  it  is  born  with  tuberculosis. 

The  weakened  organs  of  the  mother  (due  to  an  unstable  nerv- 
ous system)  may  cause  the  child  to  inherit  an  unstable  nervous 
system.  This,  in  turn,  may  cause  an  arrested  or  excessive  devel- 
opment of  the  jaw  and  alveolar  process  in  the  child  at  the  periods 


^Talbot.     Degeneracy:  Its  Signs,  Causes  and  Effects. 


96  INTERSTITIAL    GINGIVITIS. 

of  stress.  Under  such  conditions  the  jaw  is  most  frequently 
arrested.  An  arrested  jaw  and  alveolar  process  usually  mean  an 
irregular  dental  arch  in  which  the  teeth  are  so  closely  packed 
(owing  to  the  crowns  being  straight,  not  bell-shaped)  that  the 
alveolar  process  is  almost  entirely  destroyed  between  the  teeth. 
To  keep  the  gum  margins  clean  and  in  a  healthy  condition  in  such 
a  mouth  is  almost  impossible.  The  slightest  inflammation,  due 
to  irritation,  of  the  gums,  peridental  membrane  or  alveolar  proc- 
ess, whether  local  or  constitutional,  will  cause  its  destruction 
sooner  or  later  in  the  life  of  the  individual. 

Again,  because  the  alveolar  process  is  a  transitory  structure 
as  well  as  an  end  organ,  and  because  of  its  thinness  around  the 
teeth,  the  inheritance  of  a  lowered  vitality,  both  in  the  individual 
or  in  the  immediate  structure  under  discussion,  or  both,  will  fur- 
nish a  predisposing  cause  for  interstitial  gingivitis.  This  is  why 
so  many  neurotic  and  degenerate  children  possess  irregular  jaws 
and  teeth,  and  why  these  children  early  develop  interstitial  gin- 
givitis.- Hence  heredity  may  well  be  the  indirect  cause  of  inter- 
stitial gingivitis. 

The  reported  cases  of  direct  heredity  in  the  pyorrhoeic  stage 
of  interstitial  gingivitis  may  belong  in  one  or  the  other  of  these 
categories,  but  such  a  theory  can  hardly  be  considered  tenable. 
Researches  of  many  able  investigators  have  failed  to  demon- 
strate the  germ  theory,  local  or  inherited,  in  causal  relation  to 
interstitial  gingivitis,  as  practiced  by  specialists,  as  we  shall 
see  in  Chapter  XII.  It  is  known,  however,  to  every  specialist 
that  the  secondary  condition  of  this  disease  (pyorrhoea  alveola- 
ris)  is  due  to  germ  infection.  Pus  germs  producing  the  sec- 
ondary stage  of  the  disease,  are  local  in  nearly  every  mouth  and 
are  not  supposed  to  be  inherited.  Pus  germs  in  the  mouth  do 
not,  apparently,  produce  the  first  stage  of  the  disease  (intersti- 
tial gingivitis),  which  is  simple  inflammation.  We  could  hardly 
expect  to  find  directly  inherited  germs  from  the  mother  to  the 
child  causing  infection  of  the  gums,  peridental  membrane  or 
alveolar  process  later  in  the  child's  life,  since  there  is  a  period 
between  birth  and  the  eruption  of  the  temporary  teeth  where 
no  alveolar  process  is  present  and  no  infection  takes  place. 


Talbot.    Developmental  Pathology:  A  Study  in  Degenerative  Evolution. 


HEREDITY  AND  ENVIRONMENT. 


97 


Transitory  organs  are  bound  to  be  weakened  by  heredity, 
both  in  their  structure  and  in  their  resistance  to  morbific  germs 
and  agencies.  These  weaknesses  are  especially  apt  to  be  empha- 
sized during  the  second  and  third  periods  of  stress'',  when  the 
temporary  and  permanent  teeth  are  erupting.  Such  weaknesses 
may  be  the  outcome  of  general  nerve  exhaustion  on  the  part  of 
the  parents  (the  mother  especially)  or  of  the  child  itself,  and 
they  represent  a  changed  (transformed)  heredity  far  more  com- 
monly than  a  direct.  This  heredity  may  be  more  intense  than  the 
constitutional  lack  of  health  in  the  parents.  On  the  other  hand, 
the  influence  of  intermarriage  of  several  healthy  generations 
may  so  offset  the  evil  results  of  the  defects  in  the  parents  that 
the  inheritance  of  disease  or  the  tendency  to  disease  is  slight, 
if  at  all  existing  in  the  child.  The  last  type  of  heredity,  called 
atavism  (or  *' throw-back"  by  breeders),  is  more  likely  to  work 
for  good  than  for  evil,  although  disease  effects  are  more  gener- 
ally looked  for.  Concerned  in  this  latter,  where  the  individual 
throws  back  to  immediate  remote  ancestors,  this  element  of 
atavism  tends,  through  preserving  the  type,  to  offset  the  defects 
of  immediate  heredity  and,  indeed,  often  underlies  the  apparent 
diiference  between  children  of  the  same  parents.  It  like^\^Lse 
prevents  equal  inheritance  from  both  parents,  and  sometimes 
favors  inheritance  of  strength  or  defect  from  either.  It  under- 
lies also  so-called  collateral  or  indirect  heredity  and  the  trans- 
mutation of  heredity.  By  virtue  of  this  atavism,  a  serious  nerv- 
ous defect  in  a  parent  or  parents  might  express  itself  only  in 
an  increased  tendency  to  disease  on  the  part  of  the  child's  tran- 
sitory structures  and  end  organs. 

The  periods  of  stress  are  times  in  the  life  of  man  when  cer- 
tain great  life  functions  are  developing  or  undergoing  retrogres- 
sion. These  periods  of  stress  are,  during  development  in  utero, 
during  the  first  dentition,  during  the  second  dentition  (often 
as  late  as  the  thirteenth  year),  during  puberty  and  adolescence 
(fourteen  to  twenty-five),  during  the  climacteric  (forty  to  sixty), 
when  uterine  involution  occurs  in  woman  and  prostatic  involu- 
tion in  man,  and  finally,  during  senility  (about  sixty  and  up- 
wards).    These  p.eriods  often  constitute  a  cause  for  the  produc- 


Talbot.    Developmental  Pathology:  A  Study  in  Degenerative  Evolution. 


98  INTERSTITIAL    GINGIVITIS. 

tion  of  disease  even  thoiigli  liereditary  defect  itself  be  absent 
until  tliis  time  when  it  first  makes  it  appearance. 

Another  factor  to  be  considered  in  this  connection  as  compli- 
cating the  diagnosis  of  heredity  in  interstitial  gingivitis  is  envi- 
ronment, nnderstanding  by  this  term  all  the  external  conditions 
that  can  favor  the  development  of  the  disorder.  Family  hab- 
its and  surroundings  are  apt  to  be  alike  for  every  member,  so 
that  if  anything  in  the  environment  especially  favors  the  break- 
ing out  of  a  disease  in  one  member,  the  same  cause  or  causes 
are  equally  likely  to  favor  the  occurrence  of  the  disorder  in  sev- 
eral members  or  even  generations  of  the  family,  and  this  may 
give  rise  to  a  suspicion  of  heredity.  This  consideration  applies 
to  interstitial  gingivitis,  since  the  disease  has  been  known  to 
develop  in  different  members  of  the  same  family  at  similar 
periods  of  life  and  under  the  same  conditions. 

That  constitutional  conditions  of  hereditary  origin  favor  the 
occurrence  of  interstitial  gingivitis  is  undeniable,  but  this  does 
not  mean  that  interstitial  gingivitis  itself  is  hereditary.  They 
favor  its  occurrence  just  as  they  favor  any  other  morbid  con- 
dition, by  lessening  resistance  or  by  preparing  the  way.  The 
interstitial  gingivitis  is  only  one  of  the  many  accidents  that  are 
thus  facilitated. 

So  far  as  salivary  concretions  are  to  be  regarded  as  an  excit- 
ing cause,  heredity  may  be  put  out  of  court,  since  these  (though 
varying  widely  in  different  individuals  in  the  amount  of  the 
deposits,  and  consequently  in  the  irritation  produced)  are  de- 
pendent upon  more  remote  constitutional  or  local  conditions 
and  have  no  direct  connection  mth  the  heredity.  Thus  the  vari- 
ous deposits  attributed  to  litha^mia  or  arthritic  conditions  (noto- 
riously hereditary),  are  merely  incidental  to  those  conditions 
and  not  essentially  connected  with  their  constitutional  origin. 
The  constitutional  conditions  merely  happen  to  furnish  the  irri- 
tant. 

Local  uric  acid  poisoning*  is,  as  I  have  elsewhere  shown, 
occasionally  associated  "v\ith  interstitial  gingivitis.  The  coexist- 
ence signifies  the  lowered  vitality  of  the  system  and  autointoxi- 
cation, rather  than  the  etiolgy. 


*  The  Dental  Cosmos,  1896,  page  312. 


HEREDITY  AXD  ENVIRON MEXT.  99 

The  same  is  true  of  all  the  other  neurotic,  rachitic  and  degen- 
erative conditions,  hereditary  or  otherwise,  that  are  met  ^^^.th, 
associated  with  gingival  inflammation.  They  favor  the  occur- 
rence of  the  disease  by  causing  a  w^eakened  capacity  of  resist- 
ance, thus  predisposing  to  the  attack  of  any  irritation.  The 
mouth,  resistant  as  it  ordinarily  is,  is  at  all  times  open  to  irri- 
tation and  infection.  AYhen  resistance  is  impaired  it  gives  way 
at  its  most  vulnerable  points,  and  the  gingival  margin  because 
of  its  transitory  and  end  organ  nature  is  one  of  these  points. 
Interstitial  gingivitis  is  favored  or  hindered,  like  other  disor- 
ders, by  constitutional  conditions  which  may  or  may  not  be  in- 
herited, and  which  bear  toward  it  the  relations  only  of  predis- 
posing and  accessory  causes. 

To  summarize,  therefore,  it  is  reasonable  to  suggest  that 
interstitial  gingivitis  and  pyorrhoea  alveolaris  are  not  inherited. 

Interstitial  gingivitis  is  the  primary  condition  and  represents 
the  reaction  of  a  weakened  transitory  end  organ  to  constitu- 
tional or  local  irritation. 

Heredity,  direct  and  indirect,  may  of  course  weaken  resist- 
ance and  predispose  to  the  disease,  particularly  in  a  structure 
so  transitory  as  the  alveolar  process,  but  no  direct  transmission 
of  infection  is  either  demonstrable  or  even  tenable. 

Pyorrhoea  alveolaris  is  a  secondary  infection  grafted  on  the 
original  inflammation  by  the  agency  of  local  pyorrhceic  germs 
such  as  are  prone  to  invade  any  exposed  membrane,  and  have 
no  relation  whatever  to  hereditv. 


CHAPTER  XI. 

DEGENERATE    TISSUES   IN    INTERSTITIAL    GINGIVITIS. 

One  important  factor  of  predisposition  to  interstitial  gingi- 
vitis is  degeneracy,  either  local  or  general.  Three  possibilities 
of  life  await  each  living  being.  The  individual  may  remain 
primitive  and  unchanged,  progress  toward  a  higher  type  or 
retrogress  to  a  lower  type.  In  these  three  conditions,  the  fact- 
ors underlying  the  stable  state  force  the  structures  to  remain 
as  they  are;  those  underlying  the  progressive  tendency  make 
them  more  elaborate,  while  the  third  tends  to  simplify  structure. 
Degeneracy  is  a  gradual  change  of  structure  by  which  the  organ- 
ism becomes  adapted  to  less  varied  and  less  complex  conditions 
of  life.  It  is  a  reverse  of  development  which  proceeds  from  the 
indefinite  and  homogeneous  to  the  definite  and  heterogeneous 
with  a  loss  of  explosive  force  due  to  the  acquirement  of  inhibi- 
tions or  checks.  In  proportion  to  the  depth  of  degeneracy  does 
it  affect  the  early  simpler  or  late  complicated  acquisitions.  The 
opposite  process  of  progression  is  a  gradual  change  of  struc- 
tures by  which  the  organism  becomes  adapted  to  more  varied 
and  more  complex  conditions  of  life.  In  progression  there  is  a 
new  expression  of  form  corresponding  to  new  perfection  of 
work  in  the  animal  machine.  In  degeneracy,  there  is  suppres- 
sion of  form  corresponding  to  cessation  of  work.  Elaboration 
of  some  one  organ  may  be  the  necessary  accompaniment  of 
degeneracy  in  all  the  others.  On  the  other  hand,  degeneracy  in 
one  organ  may  be  the  necessary  accompaniment  to  elaboration 
in  all  the  other  organs.  During  any  of  the  periods  of  stress 
defects  due  to  degeneracy  are  apt  to  appear  and  affect  the  line 
of  least  resistance,  determined  by  the  depth  of  degeneracy,  as 
well  as  the  variability  of  the  structures  concerned.  This  is  the 
reason  certain  individuals  develop  disease  or  become  suscepti- 
ble to  disease  since  at  these  periods  the  entire  organism  under- 
goes change,  and  the  organs  most  affected  by  degeneracy  are  the 


DEGENERATE  TISSUES  IN  INTERSTITIAL  GINGIVITIS.  101 

first  involved.  This  is  particularly  true  of  transitory  structures 
like  the  alveolar  proccess  and  it,  in  addition  to  being  doubly 
transitory  and  the  most  sensitive  structure  in  the  body  is  also 
an  end  organ  like  the  brain,  eye  and  kidney.  The  teeth  and  jaws 
are  among  the  most  variable  structures  in  the  body,  and  they 
are  peculiarly  apt  to  be  affected  by  either  general  degeneracy, 
which  affects  the  body  as  a  whole,  of  local  degeneracy,  which 
may  aif  ect  one  organ  or  structure  or  part  of  them.  Degeneracy 
factors  causing  nervous  exhaustion  in  the  parents  leave  their 
stamp  on  the  tonicity  of  the  child's  organs  to  combat  disease. 
Every  nerve  cell  has  two  functions,  namely:  sensation  or 
motion  and  growth  which  are  dependent  upon  each  other,  that  is, 
if  the  cell  be  tired  by  excessive  work  along  the  line  of  sensation 
or  motion,  growth  later  becomes  impaired.  The  cell  then  not 
only  ceases  to  continue  in  strength,  but  becomes  self-poisoned. 
Each  of  the  organs  (heart,  liver,  kidneys,  etc.)  has  its  own  sys- 
tem of  nerves  (the  sympathetic  ganglia)  which  while  under  the 
control  of  the  spinal  cord  and  brain,  act  independently.  If  these 
nerve  centers  become  tired,  the  organ  fails  to  perform  its  func- 
tions, the  general  system  becomes  both  poisoned  and  ill-fed,  and 
nervous  exhaustion  results.  In  most  cases,  however,  the  brain 
and  spinal  cord  are  first  exhausted.  The  nerves  of  the  other 
organs  are  thus  allowed  too  free  play,  and  exhaust  themselves 
later.  This  systemic  nerve  exhaustion  particularly  affects  the 
testicle  in  the  male  and  the  uterus  and  ovaries  in  the  female, 
hence  an  unstable  nervous  system  in  the  offspring  results. 
Through  this,  the  body  is  imperfectly  supplied  with  natural 
tonics  (antitoxins)  formed  by  these  structures,  and  the  general 
nervous  exhaustion  becomes  still  more  complete.  All  the  organs 
of  the  body  are  thus  weakened  in  their  function.  Practically 
the  neurasthenic's  organs  have  taken  on  degenerative  functions 
though  not  degenerate  in  structure.  Through  the  influence  of 
these  various  nerve  exhaustion  agencies,  the  spinal  cord  and 
brain  lose  their  phylogenetic  gains  and  the  neurasthenic  is  no 
longer  adjusted  to  environment.  Since  the  reproductive  organs 
suffer  particularly,  children,  born  after  the  nervous  exhaustion 
in  the  parents,  are  more  or  less  checked  in  development  owing 
to  the  depth  of  degeneracy  and  the  influence  of  healthy  atavism. 


102  INTERSTITIAL    GINGIVITIS. 

Tlioy  have  degenerations  in  the  structure  of  their  organs  which, 
in  the  parents  were  represented  by  neurasthenic  disorder  in 
function.  As  the  ovaries  of  the  neurasthenic  female  generally 
exhibit  prominently  the  effects  of  nervous  exhaustion,  the  off- 
spring does  not  retain  enough  vigor  to  pass  through  the  normal 
process  of  growth  or  should  it  survive,  it  is  usually  affected  by 
the  profound  neuroses.  In  these  instances  in  connection  with 
irregular  dental  arches,  there  is  always  interstitial  gingivitis 
and  pyorrhoea  alveolaris. 

The  action  of  degeneracy,  considered  as  a  local  factor  of  con- 
stitutional origin,  may  be  exerted  to  preserve  embryonic  con- 
ditions in  adult  life.  Such  preservation  may  result  in  the  break- 
dow^n  of  tissues  which  would  otherwise  withstand  germs,  toxins 
and  poisons,  or  other  causes  of  disease  external  to  the  tissues. 
Given  this  condition  of  local  degeneracy,  a  local  predisposing 
factor  is  added  to  both  the  exciting  causes  and  the  constitu- 
tional predisposing  factors.  So  long  as  the  teeth  and  transi- 
tory structures  remain  in  the  comparatively  stable  condition  of 
primitive  races,  this  factor  is,  to  a  great  extent,  in  abeyance. 
When,  however,  the  jaw  begins  to  evolve  (grow  smaller),  the 
degenerate  types  find  this  factor  adding  dangers  in  their  pliylo- 
geny.  In  the  degenerate,  the  struggle  for  existence  between 
organs  (the  brain  and  skull  on  the  one  hand,  and  the  face,  jaws 
and  teeth  on  the  other)  is  not  properly  balanced,  whence  the 
dangers  from  these  local  states  of  degeneracy  that  in  the  higher 
types  are  expressions  of  advance  undergone  without  danger. 
This  is  excellently  illustrated  in  the  embryology  of  the  mucous 
membrane.  This,  in  degenerate  children,  often  fails  so  to  de- 
velop that  the  bactericidal  function  of  mucus  does  not  appear. 
This  hereditary  feebleness  of  the  mucous  membrane  is  pecu- 
liarly apt  to  occur  in  the  nose,  throat  and  gums,  but  other  mu- 
cous membranes  are  not  exempt. 

Miller,  as  elsewhere  stated,  found  a  little  over  thirty-three 
and  one-third  per  cent  on  examination  of  tw^enty-six  rachitic 
children  under  twelve  years  wdio  manifested  interstitial  gingi- 
vitis. Considering  that  most  of  these  manifested  symptoms 
of  inherited  congenital  or  acquired  constitutional  defect,  such 
a  small  proportion  is  rather  remarkable.    The  fact  suggests  one 


DEGENERATE  TISSUES  IN  INTERSTITIAL  GINGIVITIS.  103 

of  two  explanations — either  the  children  in  the  institution  vis- 
ited by  Doctor  Miller  took  better  care  of  their  teeth  and  gums 
than  is  usual  ">\itli  this  class,  or  the  cases  in  which  pus  existed 
only  were  classed  as  pyorrhoea.  I  have  examined  the  mouths 
of  deaf  mutes,  blind,  idiotic,  feeble-minded  and  rachitic  children 
in  the  institutions  in  America  and  Europe.  Interstitial  gingivi- 
tis was  found  in  all  its  stages,  from  simple  inflammation  of  the 
gums  to  loosening  of  the  teeth,  in  from  twenty-five  to  seventy- 
five  per  cent.  In  these  cases  not  only  are  there  constitutional 
factors,  but  also  uncleanliness  of  the  mouth  and  gum  tissues. 
The  degenerate  children  of  even  the  best  families  encountered 
in  office  practice  usually  have  jaw  deformities  and  teeth  irregu- 
larities as  well  as  interstitial  gingivitis.  Patterson  has  had 
under  observation  thirty-eight  cases  of  well-marked  pyorrhoea, 
thirty-three  of  w^hich  co-existed  with  nasal  catarrh.  These 
cases  were,  no  doubt,  those  of  degenerate  patients.  The  nasal 
catarrh  was  a  coincidence  dependent  on  the  general  deficiency 
of  the  mucous  membrane. 


CHAPTER  XII. 

BACTEKIOl.OGIC    RESEARCHES    IN    INTERSTITIAL    GINClVITIS. 

The  causes  which  in'oduce  interstitial  gingivitis  may  be 
divided  into  those  producing  infections  and  those  producing  irri- 
tations from  intoxication. 

The  infections  may  be  divided  into  local  and  constitutional. 
The  constitutional  infections  are  those  which  infect  the  gums, 
alveolar  process  and  peridental  membrane,  through  the  blood, 
such  as  tuberculosis,  syphilis,  scurvy  and  similar  diseases. 

The  local  infections  are  those  in  wliich  the  germs  infect  the 
tissues  directly  producing  anthrax,  actinomycosis,  gonorrhoea, 
syphilis,  apthae,^  dead  pulps  and  many  other  diseases  for  which 
no  name  has  yet  been  applied. 

All  these  diseases  have  constitutional  symptoms  which  are 
associated  and  which  must  be  understood  in  making  a  diagnosis. 
Since  most  of  these  infections,  whether  constitutional  or  local, 
are  special  diseases  of  the  gums  and  alveolar  process,  they  re- 
quire special  constitutional  treatment  according  to  the  general 
s3^mptoms  as  they  arise  and  are  therefore  to  be  placed  in  a  spe- 
cial class  by  themselves.  They  are  not  considered  again  in  this 
work. 

Experiments  with  bacteric  infection  upon  animals  and  human 
to  produce  interstitial  gingivitis  have  been  made  by  Galippe, 
Miller,  Rhein,  Carpenter  and  Talbot. 

Galippe  "  was  probably  among  the  first  to  make  analj^tic 
experimentation  in  the  bacteriology  of  this  disease.  He  claims 
that  there  is  found  in  the  pus  of  pyorrhoea  a  parasite,  resembling 
in  shape  the  Greek  letter  N.  Injecting  this  into  the  belly  of  a 
guinea  pig,  abscesses  resulted,  which  had  a  special  tendency  to 
affect  bone  tissue.  Injections  into  the  space  between  the  teeth 
and  gums  were  negative  in  result.    Galippe  regards  his  experi- 


^  Talbot.     Some  Bacterial  and  Non-bacterial  Diseases.     Journal  of  the  American 
Medical  Association,  February  10,  1912. 

'Die  Infectiose  ArthroDentaire  Gingivitis,  1888. 


BACTEKIOLOGIC    RESEARCHES    IX    INTERSTITIAL    GINGIVITIS.       105 

ments   as   suggestions   for   fiirtlier   research,   but   not   demon- 
strative. 

Miller,^  after  explaining  liis  own  methods,  made  a  series  of 
culture  experiments  on  agar-agar  at  blood  temperature.  Twelve 
cases  of  pyorrhoea  in  human  beings,  and  six  in  dogs,  were  exam- 
ined. He  isolated  twenty  different  bacteria  from  human  beings, 
and  nine  from  dogs.  Among  the  twenty  kinds,  staphylococcus 
pyogenes  aureus  was  found  twice,  staphylococcus  pyogenes 
albus  once,  streptococcus  pyogenes  once.  Of  the  other  sixteen, 
nine  subcutaneously  injected  produced  no  particular  reaction, 
four  a  slight,  three  a  severe  suppuration  in  the  subcutaneous 
connective  tissue.  .  .  .  Among  the  nine  species  found  in 
dogs,  staphylococcus  pyogenes  albus  occurred  once.  Of  the 
other  eight,  two  subcutaneously  injected  caused  no  reaction,  and 
five  but  slight.  One  caused  very  profuse  suppuration,  by  which 
large  portions  of  skin  exfoliated.  .  .  .  Microscopic  exami- 
nation of  stained  sections  revealed  masses  of  different  bacteria, 
cocci  and  bacilli.  Leptothrix  occurred  infrequently,  and  then 
only  on  the  surface  of  the  cement,  and  where  there  were  micro- 
scopical cavities  in  it.  .  .  .  Miller  succeeded  consequently 
in  cultivating  a  large  number  of  bacteria  from  pyorrhoea  alveo- 
laris  which  possessed  pyogenic  properties,  but  was  not  able  to 
determine  the  constant  occurrence  of  any  one  which  might  be 
regarded  as  the  specific  micro-organism  of  pyorrhoea  alveolaris. 
Miller  remarks  that  it  is  not  evident  from  Galippe's  communica- 
tion whether  he  found  the  N  or  B  bacterium  in  all  cases  exam- 
ined, or  but  once. 

Sudduth,  after  repeated  examinations,  arrived  at  the  same 
conclusion  as  Miller. 

Dr.  M.  L.  Rhein's*  investigations  are  here  given.  He  says, 
''The  results  of  my  investigations  made  at  the  Pediatric  Labora- 
tory in  New  York  some  eleven  years  ago  are  given  here  for  the 
first  time  as  corroborative  e\'idence  that  in  healthy  bodies  it  is 
impossible  to  produce  this  disease.  Four  guinea  pigs,  proven 
.  later  at  the  autopsy  to  be  absolutely  free  from  any  taint  of  dis- 
ease or  abnormality,  were  chosen.    Their  food  was  carefully  re- 


'  Micro-Organisms  of  the  Human  Month. 

*  Pyorrhcea  Alveolaris.     The  Items  of  Interest,  June,  1910. 


106  INTERSTITIAL    GINGIVITIS. 

duced  day  by  day  until  they  died  at  the  end  of  ten  weeks.  Con- 
trol pigs  were  kept  in  a  cage  alongside  of  these  and  fed  with 
the  usual  quantities  of  food.  About  the  beginning  of  the  tenth 
week  when  the  pigs  were  w^eakened  from  lack  of  food,  all  eight 
of  them  were  inoculated  in  the  pericemental  regions  with  injec- 
tions of  liquid  cultures  developed  in  bouillon,  from  pus  taken 
from  the  pockets  of  pyorrhoeal  patients.  On  the  third  day  all 
evidence  of  the  trauma  produced  by  the  injections  had  disap- 
peared. At  no  time  had  there  been  the  slightest  evidence  of 
even  a  resulting  gingivitis.  As  stated  before,  the  autopsies 
showed  all  four  pigs  to  have  absolutely  normal  organs,  although 
they  were  practically  skeletons.  Of  the  control  pigs,  while  three 
of  them  showed  the  same  immunity  to  infection,  the  fourth  one 
showed  evidence  of  inflammation,  and  at  the  end  of  the  fifth  day 
there  was  a  distinctive  serus  exudate  coming  from  the  neck  of 
the  front  tooth  around  which  the  injections  had  been  made.  I 
have  always  regretted  the  fact  that  this  pig  was  not  killed  and 
an  autopsy  held. 

''Before  this  time  I  had  examined  the  mouths  of  many  hun- 
dreds of  guinea  pigs  inoculated  by  the  Board  of  Health  with 
tuberculosis.  Every  one  of  these  showed  the  most  marked  evi- 
dence of  pyorrhoeal  conditions.  In  the  same  manner  a  visit  to 
any  sanatorium  for  tuberculosis  cases  will  show  on  examination 
of  the  mouths,  pyorrhoea  alveolaris  in  a  degree  of  severity 
exactly  conforming  to  the  inroads  which  the  disease  has  made. 
A  like  examination  of  the  medical  wards  of  any  hospital  con- 
taining cases  of  diseases  of  the  heart,  kidneys,  liver,  lungs,  etc., 
will,  if  no  attention  has  been  paid  to  prophylaxis  of  the  mouth, 
show  conditions  of  pyorrhoea.  Even  when  the  most  strenuous 
efforts  in  this  direction  of  mouth  care  are  taken,  if  the  form  of 
the  malnutrition  has  passed  to  a  certain  stage,  no  care  of  the 
mouth  is  sufficient  to  prevent  the  marked  development  of  pyor- 
rhoea alveolaris." 

The  results  obtained  in  the  Columbus  Memorial  Laboratory 
of  Chicago,  by  W.  A.  Evans  for  the  author,  were  as  follows : 

In  order  to  determine  whether  a  specific  bacterium  existed  in 
the  pyorrhoeic  stage  of  interstitial  gingivitis  in  man  (necessary 
to  constitute  this  stage  a  special  disease),  pus  from  more  than 


BACTERIOLOGIC    EESEARCHES    IX    INTERSTITIAL    GINGIVITIS,       107 

fifty  cases  was  examined.  In  all,  the  pus  was  obtained  from  the 
gums  by  a  platinum  needle  under  proper  methods  of  steriliza- 
tion. The  pus  from  some  cases  was  smeared  on  a  slide.  This 
was  stained  and  such  determination  made  as  was  possible  with 
this  procedure.  With  the  pus  from  fifteen  cases,  agar  was  inocu- 
lated and  placed  in  Petrie's  dishes.  The  individual  colonies 
were  grown  on  gelatin,  agar,  bouillon,  potato  and  blood  serum. 
The  results  were  as  follows:  In  fifteen  cases  in  which  the 
organisms  were  plated  out,  fifty-five  organisms  w^ere  found.  In 
two  there  was  no  grow^th.  Two  had  but  one  species  of  germs, 
two  had  six,  one  had  seven,  and  one  had  ten.  The  germs  found 
are  divisible  into  three  classes:  Those  usually  pathogenic  to 
man,  those  exceptionally  pathogenic  to  man,  and  those  never 
pathogenic  to  man.  The  first  class  was  found  thirty  times,  the 
second  twelve,  and  the  third  thirteen.  Class  third  is,  no  doubt, 
seemingly  smaller  than  it  should  be,  since  many  members  of  it 
probably  do  not  grow  on  ordinary  culture  media.  Of  the  germs 
most  frequent  and  important,  staphylococcus  pyogenes  aureus 
occurred  nine  times,  staphylococcus  pyogenes  albus  six  times, 
and  staphylococcus  pyogenes  citreus  once.  A  lanceolate  diplo- 
coccus,  growing  like  pneumonococcus,  was  found  six  times. 
Streptococcus  pyogenes  w^as  found  twice.  Bacillus  coli  com- 
mune was  found  twice.  A  bacillus  growing  like  the  diphtheria 
bacillus  occurred  twice.  This  last  bacillus  had  the  appearance 
of  the  Klebs-Loeffler  l)acillus.  It  lay  on  the  slide  like  it  and  it 
stained  irregularly.  Of  the  less  important  organisms,  bacillus 
P3^ocyaneus  was  found  three  times,  micrococcus  tetragenus  seven 
times,  leptothrix  seven  times,  bacillus  mesentericus  twice,  bacil- 
lus subtilis  three  times.  There  was  also  present  a  peculiar  large 
club-shaped  fungus  somewhat  resembling  the  degenerative 
forms  of  actinomycosis. 

Did  these  examinations  stand  alone,  definite  conclusions 
could  not  be  drawn  from  them.  These,  however,  are  admissible 
since  all  observations  on  this  subject  tend  in  the  same  direction. 
While,  as  already  stated,  Galippe  believed  that  he  had  isolated 
two  bacteria  capable  of  causing  pyorrhoea  alveolaris,  still  he 
failed  with  both  to  produce  the  disease.  This  failure,  according 
to  the  laws  of  Koch,  is  fatal  to  the  position  taken. 


108  INTERSTITIAIi    GINGIVITIS. 

M.  Herzog,  of  the  Cliicago  Polyclinic,  on  examination  of 
cases  of  interstitial  gingivitis,  wliicli  had  not  readied  the  pyor- 
rhoeic  stage,  had  the  following  results:  Pieces  from  the  gum 
margin  which  had  been  fixed  and  hardened  in  a  formalin  solu- 
tion, were  partly  imbedded  in  celloidin,  partly  in  paraffin.  The 
sections  were  stained  according  to  various  methods,  including 
Gramm's,  eosin  (Unna's)  and  alkaline  methylblue  stain.  The 
examination  of  the  tissue  shows  an  unchanged  lining  of  stratified 
squamous  epithelium,  and,  in  the  connective  tissue  below  the 
former,  well-marked  evidences  of  an  inflammatory  process.  The 
round-cell  infiltration  is  best  marked  in  the  deeper  layers  toward 
the  periosteum,  while  the  layers  of  connective  tissue  fibers  nearer 
to  the  lining  epithelium  show  less  evidences  of  inflammation  and 
are  partly  entirely  free  from  any  round-cell  infiltration.  The 
infiltrating  round  cells  are  of  the  type  of  lymphocytes,  plasma 
cells  and  plasma  mast  cells.  Very  large  and  typical  mast  cells 
are  frequently  found  in  the  neighborhood  of  small  vessels. 
Many  of  the  vessels  seen  are  quite  tortuous,  and  the  vascular 
supply  of  the  connective  tissue  appears  to  be  considerably  in- 
creased beyond  the  normal.  Bacteria  could  not  be  demonstrated 
in  the  inflamed  areas. 

M.  Herzog 's  examination  of  the  interstitial  gingivitis,  pro- 
duced by  mercury  in  dogs,  failed  to  reveal  any  bacteria.  He  was 
of  opinion  that  the  histologic  changes  of  inflammatory  type 
found,  were  due  to  the  chemotactic  influence  of  mercury  and  not 
to  microbic  action. 

In  a  paper  ^  read  before  the  Section  on  Stomatology  of  the 
American  Medical  Association,  at  Columbus,  Ohio,  George  T. 
Carpenter  mentioned  some  very  interesting  experiments  in  this 
connection.  By  infecting  a  fresh  wound  in  the  gums  of  rabbits 
with  pyorrhoea  and  other  pus  he  found  the  parts  will  remain 
infected  only  from  two  to  five  days.  In  other  rabbits  a  rubber 
band  was  placed  around  teeth  and  pressed  under  the  gums  until 
inflammation  resulted,  when  the  parts  were  infected  with  pyor- 
rhoea and  pus  from  a  chronic  ulcer;  pus  infection  resulted. 

Like  experiments  were  made  in  the  human  mouth  on  gums 


^Some  Points  on  the  Etiology,  Pathology  and  Treatment  of  Persistent  Pyorrhcea 
Alveolaris. 


BACTERIOLOGIC    EESEAECHES    IJ^    INTERSTITIAL    GINGIVITIS.       109 

which  had  been  neglected  as  well  as  on  healthy  gums,  and  with 
similar  results.  His  experiments  tend  to  show  that,  when  ani- 
mals and  man  are  healthy,  the  tissues  resist  infection ;  but  when 
diseased,  infection  results.    All  yield  to  treatment. 

On  examination  of  pus  taken  from  pyorrhoea  pockets  pro- 
ceeding from  acute  infection,  two  competent  bacteriologists  were 
unable  to  find  a  micro-organism  not  found  in  pus  from  other 
infected  tissues. 

These  results,  in  Carpenter's  opinion,  tend  to  show  that  a 
specific  germ,  to  which  pyorrhoea  alveolaris  is  attributable,  has 
not  yet  been  found. 

The  disease  being  so  prevalent  among  dogs,  it  occurred  to  me 
that  they  would  be  of  great  value  for  experimental  inoculation. 
The  prevalence  of  the  disease  in  dogs  suggests  that  if  it  were  a 
specific  infection,  these  must  be  inoculable.  Miller  '^  had  made  a 
few  inoculations  of  pus  as  well  as  of  the  deposits  around  the 
teeth.  Slight  inflammation,  and,  in  one  case,  a  little  suppuration 
alone  resulted.  He  afterward  isolated  twenty  different  bacteria 
from  the  human  mouth  and  nine  from  dogs.  Some  of  the 
uncommon  varieties  were  infective,  l)ut  without  marked  results. 
Isolated  varieties  would  probably  not  produce  results  that  could 
be  attained  by  inoculating  animals  with  the  fresh  secretion  (pus 
and  other  deposits)  from  dogs  already  affected  with  the  disease. 
A  dog  was  procured  from  the  Veterinary  Hospital  whose  gums 
and  outer  alveolar  process  were  almost  entirely  absorbed  with 
pus  exudate.  Street  dogs  selected  for  inoculation  were  forty-six 
in  number,  ranging  in  age  from  one  year  to  seven.  They  w^ere 
of  all  breeds  and  conditions.  Some  were  well  fed,  others  very 
thin.  Many  had  sound,  healthy  gums ;  others  had  slight  inflam- 
mation at  different  localities.  No  dog  was  used  whose  gums 
and  alveolar  process  had  become  infected  or  whose  tissues  were 
absorbed.  Two  dogs  were  operated  upon  at  a  time.  The  gum 
was  separated  from  the  necks  of  the  teeth  down  to  the  alveolar 
process  and  peridental  membrane — one  half  at  the  canine,  the 
other  at  the  second  pre-molar,  since  in  a  majority  of  cases  the 
disease  began  at  the  canine  tooth,  probably  on  account  of  its 
prominence  and  the  thinness  of  the  alveolar  process.     The  sec- 


Mifro-Organisnis  of  the  Human  Mouth,  page  329. 


110  INTERSTITIAL    GINGIVITIS. 

Olid  pre-molar  was  selected  because  it  is  the  least  prominent. 
The  secretions  about  the  teeth  and  gnnis  of  the  diseased  dog 
were  collected  upon  a  platinum  wire  (previously  sterilized)  and 
conveyed  to  the  injured  parts.  Thirty-nine  healed  in  eight  days. 
In  these  the  gum  tissues  were  healthy.  The  pus  had  no  effect. 
The  wounds  healed  as  rapidly  as  any  wounds  possibly  could. 
In  seven  the  gums  were  inflamed  and  infection  occurred.  Sup- 
puration was  slight  in  four  and  considerable  in  three.  The  path- 
ologic findings  in  these  cases  were  not  unlike  inflamiuation  and 
infection  in  other  tissues.  Similar  results  would,  no  doubt,  have 
taken  place  if  inoculation  had  been  performed  with  pus  from  an 
abscess.  The  last  three  dogs  were  allowed  to  depart  at  the  end 
of  four  weeks  with  slight  pus  infection. 

Since  these  researches  were  concluded,  another  series  of  ex- 
periments was  undertaken  upon  the  lines  conducted  by  Dr. 
Carpenter,  extending  over  a  period  of  twelve  years.  These  ex- 
periments were  performed  upon  dogs,  guinea  pigs,  rabbits,  white 
Qiice,  and  humans.  One  hundred  and  seventy-six  experiments 
were  made.  They  consisted  of  the  application  of  pus  from 
pyorrhea  patients  direct  to  healthy  and  diseased  gums  with  a 
view  of  producing  interstitial  gingivitis  or  pyorrhoea  alveolaris 
or  both.  Applications  were  made  to  fifty-six  humans,  twenty-six 
had  slightly  inflamed  gums  and  thirty  comparatively  healthy 
gums.  Forty-eight  dogs  were  treated  in  like  manner;  twenty- 
nine  young  dogs  had  healthy  gums  and  nineteen  older  dogs 
slightly  diseased  gums ;  thirty-two  guinea  pigs ;  eighteen  rabbits 
and  twenty-two  white  mice.  While  a  slight  inflammation  was 
produced  in  a  part  of  those  cases  where  inflammation  already 
existed,  no  extended  chronic  inflammation  resulted.  We  would 
naturally  expect  to  obtain  some  results  in  the  white  mice  since 
they  are  of  the  degenerate  type  and  very  susceptible  to  disease 
but  the  results  were  similar  to  those  of  other  animals.  These 
experiments  may  later  seem  crude  and  with  improved  methods 
better  results  may  be  obtained. 

Outside  of  a  few  specific  diseases  of  the  gums  and  alveolar 
process  some  of  which  have  already  been  enumerated,  no  one 
has  demonstrated  that  specific  pathogenic  bacterial  infection 
is  a  cause  of  interstitial  gingivitis  although  the  mouth  is  known 


BACTERIOLOGIC    RESEARCHES    IX    INTERSTITIAL    GINGIVITIS.       Ill 

to  be  the  breeding  ground  of  an  extensive  variety  of  germs. 
Teetli  are  extracted,  irregular  teeth  are  corrected,  healthy  gums 
are  injured  in  filling  teeth  and  finishing  fillings  many  times  each 
day  but  we  seldom  see  local  infection  of  the  gums  and  alveolar 
process,  producing  interstitial  gingivitis  which  comes  to  us  every 
day  for  treatment. 

In  these  diseased  conditions,  mechanical  specialists  spend 
hours  on  the  surgical  treatment  of  the  gums,  peridental  mem- 
brane and  alveolar  process  surrounding  the  tooth  without  first 
destro}T-ng  the  pus  germs  about  the  teeth,  injuring  the  parts 
and  carrying  the  pathogenic  bacteria  into  the  wounds.  If  infec- 
tion were  a  cause,  such  rash  treatment  surely  would  intensify  the 
disease.  Some  of  the  lower  vertebrates,  such  as  the  carnivora 
live  upon  putrid  food  containing  all  forms  of  pathogenic  bac- 
teria but  gum  infection  rarely,  if  ever,  takes  place. 

Within  the  past  year  a  machine  has  been  placed  upon  the 
market  for  the  supposed  purpose  of  forcing  oxygen  through  the 
tissues  in  the  treatment  of  this  disease.  I  have  watched  this 
process  of  treatment  "with  fear  and  trembling"  since  the 
method  of  application  forces  the  pus  germs  through  the  inflamed 
alveolar  process.  Why  infection  does  not  occur  is  a  mystery. 
This  method  of  applying  drugs  and  forcing  pus  germs  into  the 
tissues  without  infection  is  a  strong  point  in  favor  of  the  non- 
infectious theory  of  interstitial  gingivitis. 

From  our  knowledge  based  upon  original  researches  at  the 
present  time,  interstitial  gingi\atis,  from  the  viewpoint  of  the 
specialist,  cannot  be  classed  as  an  infectious  disease.  It  may  be 
possible  in  the  future  with  more  improved  methods  of  research 
to  throw  a  clearer  light  on  the  nature  of  the  process. 


CHAPTER  XIII. 

INTERSTITIAL    GINGIVITIS, 

Interstitial  gingivitis  is  an  inflammation  wliicli  ma}^  take 
place  in  the  gums,  peridental  membrane  and  alveolar  process  at 
any  point  from  the  gingival  border  to  the  apex  of  the  root  or 
roots  of  the  tooth.  This  inflammation  may  be  confined  to  a  very 
small  area  at  any  one  of  these  locahties  and  progress  to  abscess 
and  be  restored  to  health  without  other  parts  becoming  involved 
or  the  entire  structure  may  become  diseased  resulting  in  the 
exfoliation  of  the  tooth. 

To  illustrate,  among  the  local  causes  tartar  or  other  irritants 
at  the  gum  margin  will  set  up  a  gingi\itis.    Remove  the  irritant 
and  by  local  treatment  the  gums  are  restored  to  health.     The 
interstitial  structures  have  not  been  involved.    In  autointoxica- 
tion, poisons  circulating  in  the  blood  may  and  do  collect  in  the 
arteries  midway  between  the  gum  margin  and  the  apical  end  of 
the  root,  set  up  inflammation  and  a  peridental  abscess  forms 
discharging  directly  upon  the  gum.     The  parts  heal  with  very 
little  or  no  pain  to  the  patient.    The  gum  margin  or  the  apical 
end  of  the  root  or  even  the  opposite  side  of  the  alveolar  process 
is  not  involved.     Here  we  have  an  interstitial  inflammation. 
Again  the  pulp  in  a  tooth  dies,  inflammation  takes  place  at  the 
apical  end  of  the  root  and  proceeds  to  abscess.    Here  again  we 
have  an  interstitial  inflammation  without  gingivitis.     It  is  im- 
possible, in  many  patients,  to  state  just  when  the  inflammation 
begins  and  in  most  patients  it  is  both  gingival  as  well  as  deep- 
seated.     The  term  "interstitial  gingivitis"  is  used  to  cover  all 
the  inflammation  of  the  gums,  peridental  membrane  and  alveolar 
process. 

Before  discussing  interstitial  gingivitis  we  must  first  famil- 
iarize ourselves  with  the  nature  of  the  structures  involved  since 
there  are  no  other  structures  in  the  human  l)ody  like  them  by 
which  the  pathology  can  be  compared.  The  structures  and  their 
functions  are  unicpie  in  themselves.     We  must,  therefore,  re- 


INTERSTITIAL    (ilXGIVITIS.  113 

capitulate  briefly  the  main  points  already  In'ouglit  out  in  pre- 
vious chapters  in  regard  to  the  structures  involved. 

In  the  evolution  of  the  face,  jaws  and  teeth  the  tendency  is 
for  these  structures  to  grow  smaller,  hence  the  jaws  and  alveolar 
process  are  transitory  organs.  In  this  natural  evolution  the 
influences  of  the  parents,  owing  to  excesses  tend  to  produce  tired 
out  reproductive  organs;  these  fagged  out  reproductive  organs 
in  turn  tend  to  produce  an  unstable  nervous  system  in  both 
mother  and  child.  The  most  intense  effect  is  on  structures 
which  are  transitory  and  always  tend  toward  the  least 
resistance. 

After  birth,  the  child  is  subjected  to  one  or  all  the  children's 
diseases  which  also  tend  to  produce  an  unstable  nervous  system 
in  the  child.  The  effect  of  an  unstable  nervous  system  upon  the 
child  is  to  produce  an  arrest  of  development  of  transitory  struc- 
tures and  acts  also  towards  the  line  of  least  resistance.  In  both 
conditions,  that  of  the  parents  and  that  of  the  child,  the  ten- 
dency is  to  produce  a  still  smaller  jaw  and  alveolar  process. 

Again,  in  some  of  the  lower  vertebrates,  there  is  a  succession 
of  teeth  throughout  life.  In  the  higher  vertebrates,  including 
man,  there  are  only  two  sets ;  one  is  shed  as  soon  as  it  has  served 
its  usefulness  by  absorption  of  the  alveolar  process  and  a  second 
set  takes  its  place.  As  soon  as  the  alveolar  process  has  built 
itself  about  the  teethj  the  phylogenetic  influence  is  ready  to 
remove  the  second  teeth.  In  other  words,  the  alveolar  process 
is  only  waiting  for  some  irritant  to  set  up  a  low  form  of  inflam- 
mation to  produce  absorption  of  the  bone.  AVe,  therefore,  have 
in  the  alveolar  process  a  doubly  transitory  structure.  We  have 
also  in  the  alveolar  process  an  exceedingly  sensitive  end  organ. 
The  tooth  to  all  intents  and  purposes,  so  far  as  this  disease  is 
concerned,  is  a  foreign  body.  The  arteries  and  nerves  pass 
through  the  bone  in  a  tortuous  manner  as  far  as  the  root  of  the 
tooth.  Poisons  circulating  in  the  blood  pass  to  the  end  of  the 
arteries  and  stop  setting  up  irritation  and  inflammation. 

There  are  otlier  end  organs  in  the  body  but  tlie.y  are  all  com- 
posed of  soft  tissues.  These  tissues  can  and  do  expand  when  in- 
flammation is  set  lip  and  in  many  instances  recover  health.  Not 
so  with  the  alveolar  process.    When  inflammation  takes  place  in 


114  INTERSTITIAL    GINGIVITIS. 

tliis  tissue,  expansion  of  the  arteries  cannot  take  place  and  de- 
struction occurs.  The  process  rarely  if  ever  recovers  its  lost 
tissue.  Because  the  alveolar  process  is  a  transitory  structure 
and  end  organ,  it  is  the  first  structure  in  the  body  to  respond  to 
poisons  and  toxins.  Two  illustrations  are  only  necessary  to 
prove  this  statement.  When  a  patient  who  has  been  working  in 
metals  or  drugs  visits  his  physician  for  any  ailment,  the  first 
thing  the  physician  does  is  to  examine  the  gums  to  ascertain  if 
the  patient  is  poisoned  by  the  drugs  or  metals,  this  structure 
being  the  first  to  become  diseased  and  register  the  poisons. 

Again,  when  the  physician  administers  mercury  or  potassium 
iodid  in  the  treatment  of  a  specific  disease,  he  continues  the 
treatment  until  the  gums  are  ''touched"  (inflamed),  this  symp- 
tom being  the  first  and  only  sign  that  the  system  is  under  the 
influence  of  the  drug.  In  lead  poisoning  Ave  have  the  blue  gum ; 
in  mercury,  red ;  brass,  green ;  scurvy,  red,  etc.  The  colors  are 
due  to  the  kinds  of  poisons  collected  in  the  ends  of  the  capillaries 
next  to  the  root  of  the  tooth.  These  indications  are  sufficient 
proof  of  the  statement  that  the  alveolar  process  is  the  first 
structure  involved. 

INFLAMMATION. 

It  is  not  my  intention  to  enter  into  a  minute  description  of 
the  phenomenon  of  inflammation  but  to  simply  state  as  briefly 
as  possible  how  it  is  produced  and  the  changes  which  take  place 
in  the  tissues  involved  in  the  disease  under  discussion. 

The  most  simple  illustration  of  active  inflammation  in  a 
highly  vascular  tissue  is  that  of  an  injury  to  the  fairly  trans- 
parent web  of  the  hind  foot,  tongue  or  mesentery  of  the  frog. 
The  web  of  the  foot  of  a  small  frog  is  so  thin  that  the  changes 
occurring  in  and  around  the  vessels  of  the  part  injured  can  be 
readily  found  with  the  microscope. 

With  slight  modifications  due  to  local  conditions  in  the  tis- 
sues under  examination,  the  process  of  inflammation  is  the 
same  throughout  the  entire  vertebrate  series  from  the  reptilia 
upwards. 

The  frog  is  prepared  by  destroying  the  central  nervous  sys- 
tem or  spinal  cord  by  passing  a  wire  through  the  vertebral  col- 


INTERSTITIAL    GINGIVITIS.  115 

umn  after  first  being  curarised.  The  web  of  the  foot  is  then 
placed  under  the  microscope  and  a  wound  is  made  with  a  needle. 
The  first  change  noticed  in  the  surrounding  tissue  of  the  injured 
membrane  is  a  dilatation  of  the  vessels  first  of  the  arteries  and 
then  of  the  veins.  In  the  arteries,  there  is  a  very  noticeable 
acceleration  of  the  flow  of  blood.  At  this  early  period,  there  is 
very  little  evidence  of  dilatation  of  the  capillaries.  In  the  course 
of  an  hour,  however,  expansion  can  be  readily  observed  and  the 
former  invisible  capillaries  now  fill  with  blood  and  are  quite 
easily  observed.  In  the  course  of  an  hour  or  two  there  is  a  slow- 
ing of  the  blood  current.  Before  the  wound  was  made,  there  was 
a  well-marked  central  stream  of  corpuscles  with  an  outer  zone  of 
plasma  devoid  of  corpuscles.  Now  the  central  stream  of  cor- 
puscles broadens  out  and  the  center  zone  of  plasma  becomes 
smaller  and  smaller.  As  it  narrows,  there  is  an  increasing  num- 
ber of  clear  round  blood  leucocytes  observed  traveling  at  a 
slower  rate  than  the  central  stream  and  occasionally  stopping 
beside  the  walls  of  the  vessels  and  after  a  short  detention  con- 
tinue their  course.  The  leucocytes  act  as  though  they  wish  to 
attach  themselves  to  the  walls  of  the  vessels.  The  current  be- 
comes slower  and  slower  until  there  is  a  vast  distinction  between 
the  central  and  the  peripheral  streams.  The  corpuscles  are  now 
closely  packed  together  and  fill  the  whole  surface  of  the  blood 
vessel.  The  leucocytes  now  approach  the  vessel  walls  in  large 
quantities  and  adhere  more  firmly.  While  the  current  is 
recognizable  the  action  of  the  stream  causes  the  leucocytes  to 
assume  a  pear-shaped  appearance  the  larger  round  end  pointing 
in  the  direction  of  the  current.  As  the  blood  stream  gradually 
slows  the  corpuscles  may  at  last  move  in  a  series  of  movements 
with  the  beats  of  the  heart,  while  frequently  in  the  veins  and  cap- 
illaries the  mass  of  blood  may  be  seen  moving  in  one  direction 
or  the  other.  Frequently  one  or  the  other  of  these  stages  is 
followed  by  complete  stasis  of  blood  in  the  vessels  of  the  injured 
area  for  occasionally  little  or  no  arrest  is  seen  in  the  vessels. 
Accompanying  this  stage,  there  is  already  considerable  exuda- 
tion of  clear  fluid  from  the  wound;  there  is  an  out-pouring  of 
lymph  from  the*  distended  vessels.  AVith  the  slomng  of  the 
stream^  the  leucocytes  collect  next  to  the  walls  of  the  small  veins 


116 


INTEESTITIAL    GINGIVITIS. 


and  within  the  capillaries  and  pass  from  the  interior  to  the  ex- 
terior of  the  vessels.  (Fig.  29.)  These  leucocytes  after  passing 
through  the  walls  of  the  vessels  collect  in  the  lymph  spaces  be- 
tween the  vessel  walls.  There  may  also  be  found  a  small  number 
of  red  corpuscles  distributed  among  them.  The  leucocytes  do 
not  stop  near  the  vessels  but  by  an  active  ama3boid  movement 
they  pass  on  to  the  point  of  injury.  Then  by  the  end  of  about  six 
hours  the  surrounding  area  of  the  injury  may  be  covered  by  a 
serum  filled  with  leucocytes.  Here  then  we  trace  the  first  step 
towards  the  provisional  protection  of  the  wound. 


Fig.  29. — Inflamed  Human  Mesentery  (O.smic-acid  Preparation)  ;  a,  Normal 
Trabecula;  ft,  Normal  Epithelium  (Endothelium);  c,  Small  Artery;  rf, 
Vein  with  Leucocytes  Arranged  Peripherally;  c,  White  Blood-Cells, 
Which  Have  Emigrated  or  are  Emigrating;  /,  Desquamating  Endothelium; 
/,  Multinuclear  Cells;  g,  Extravasated  Red  Blood-Cells.     x180.     (Ziegler.) 


If,  in  producing  this  wound  irritating  substances  have  not 
entered,  the  process  may  be  arrested  at  this  point.  The  stasis 
of  blood  in  the  distended  vessels  may  now  be  followed  by  a 
restoration  of  the  current  and  slow  return  of  the  vessels  to  their 
former  caliber  will  take  place. 

On  the  other  hand,  if  irritants  of  a  microbic  nature  enter  the 
wound  the  process  may  extend  to  abscess.    If  the  irritants,  in- 


INTERSTITIAL   GINGIVITIS.  117 

fections  or  poisons  are  too  abundant,  migration  of  quantities  of 
leucocytes  takes  place  and  they  collect  between  the  bundles  of 
connective  tissue  fibers.  The  cocci  collect  in  the  lymph  spaces 
and  the  massing  of  leucocytes  corresponds  to  the  accumulation 
of  the  microbes.  At  the  end  of  about  forty-eight  hours  a  com- 
plete abscess  forms,  separated  sharply  from  the  surrounding 
healthy  tissue.  In  the  center  all  traces  of  previous  blood  vessels 
are  lost,  while  in  the  periphery  they  are  easily  traceable ;  in  the 
center  of  the  abscess  the  original  tissue  has  wholly  disappeared, 
while  near  the  outer  surface,  sheaths  and  bundles  of  disinte- 
grating fibers  are  seen ;  about  the  tenth  day  new  growth  of  tis- 
sue begins  to  show  itself.  Numerous  capillaries  and  newly- 
formed  connective  tissue  are  seen  and  the  process  of  restoration 
takes  place. 

We  have  shown,  in  a  general  way,  the  different  stages  of 
inflammation  in  soft  tissues  of  all  vertebrates,  including  the 
gums  and  peridental  membrane  in  man.  The  inflammatory  proc- 
ess which  takes  place  in  the  alveolar  process,  however,  is  quite 
different  in  its  procedure.  Instead  of  the  traumatic  injury  to 
the  frog  just  cited,  the  injury  to  the  alveolar  process  is  brought 
about  by  the  poisons  and  toxins  circulating  in  the  blood  and 
which  I  have  called  constitutional  causes.  These  poisons  and 
toxins  take  the  form  of  local  disturbance,  of  innervation,  poor 
circulation  and  tissue  metabolism.  Generally  the  action  of 
poisons  is  to  contaminate  all  the  blood  which  circulates  to  the 
remote  organs.  This  general  action  of  the  poisons  and  toxins  in 
the  blood  is  added  to  the  local  action  of  irritants.  These  poisons 
act  upon  the  nerve  sheaths,  decompose  the  blood  but  mainly 
affect  the  vessel  walls.  They  also  tend  to  accumulate  in  certain 
organs  ^vithin  which  they  frequently  develop  their  chief  action 
and  often  cause  remarkable  tissue  change. 

The  principal  structures  affected  by  these  poisons  are  the 
end  organs,  namely,  the  eye,  the  brain,  the  kidney  recognized  by 
every  physician,  while  the  dental  pulp  and  alveolar  process, 
which  I  have  previously  mentioned,  are  the  most  complete  end 
organs  in  the  human  body  and  usually  first  involved.  Because 
of  the  nature  of  their  structures  and  surroundings,  symptoms  of 
disease  are  observed  in  these  structures  long  before  the  other 
end  organs  are  affected. 


118 


INTERSTITIAL    GINGIVITIS. 


The  dental  pulp  (as  before  stated)  is  the  most  complete  end 
organ  for  the  reason  that  the  blood  enters  the  tooth  by  a  single 
artery.  It  then  multiplies  until  the  pulp  is  composed  of  myriads 
of  minute  arteries  confined  within  bony  walls.  The  return  blood 
again  passes  through  the  apical  end  of  the  tooth  by  a  single 
vein.  It  is  not  uncommon,  therefore,  for  the  arteries,  filled  with 
poisons,  to  expand  and  prevent  the  return  to  circulation,  thus 
causing  numerous  diseases  and  frequently  spontaneous  death  of 
the  pulp. 

The  second  most  complete  end  organ  is  the  alveolar  process. 
It  is  the  only  bony  end  organ  in  the  human  body.    The  arteries 


o  fr 


Fig.  30. — Is  Similar  to  Tig.  10.  The  Haversian  Canal  Shows  a  Dark  Line 
Around  the  Inner  Border  Representing  the  Arterial  Wall. — The  Space 
Between  the  Dark  Line  and  the  Bone  is  Filled  with  Fibrous  Tissue. 


penetrate  the  bone  in  a  wavy  manner  as  far  as  the  root  of  the 
tooth,  which,  so  far  as  the  disease  is  concerned,  is  a  foreign  body, 
when  circulation  ceases  to  any  great  extent. 

The  simplest  illustration  of  the  action  of  these  poisons  is 
that  of  a  healthy  individual  at  the  sixth  period  of  stress  or 
about  sixty  years  of  age.  This  senile  period,  however,  may  take 
place  at  a  much  earlier  time  in  life.  The  excretory  organs  be- 
come weakened  and  the  poisons  formerly  excreted  by  the  lungs, 
kidneys,  bowels  and  skin  are  not  eliminated  but  circulate  in  the 
blood.     Odor  from  the  breatli,  skin  faeces,  an  abnormal  urinary 


INTEESTITIAL    GINGIVITIS. 


119 


acidity  degree,  indican  and  other  poisons  in  the  urine  indicate 
these  changes.  These  poisons  are  retained  in  the  peripheral 
organs  but  more  especially  in  the  dental  pulp  and  alveolar  proc- 
ess. Those  receiving  the  greatest  quantity  and  retaining  it  are 
the  ones  so  constructed  as  to  prevent  a  return  of  the  irritants  or 
poisons  to  the  circulation. 

The  irritants  cause  a  dilatation  of  the  vessels,  first  of  the 
arteries  and  then  of  the  veins.  This  dilatation  of  the  arteries 
presses  against  the  bony  walls  of  the  alveolar  process  which 
sets  up  absorption.    (Fig.  30.)     Since  the  poison  is  a  general  one 


Fig.  31. — Bone  Absorption  ky  ILalisteresis:  In  the  Middle  Space  the  Bone  is 
Just  Beginning  to  Absorb  Around  the  Artery. — The  Space  to  the  Left 
Shows  a  Large  Portion  of  Bone  Absorbed,  Leaving  the  Fibrous  Tissue  in 
Place;  While  the  Two  Spaces  at  the  Right  and  Bottom  of  the  Illustration 
Show  the  Lime  Salts  and  Fibrous  Tissue  Entirely  Destroyed. 


many  arteries  act  in  like  manner.  Chemical  changes  also  take 
place  around  the  arteries  which  assist  greatly  in  producing  bone 
absorption.  Halisteresis  is  produced  and  the  bone  quickly  dis- 
appears. Sometimes,  especially  when  only  a  small  area  is  in- 
volved lacunar  absorption  only  occurs.  The  vessels  of  Von 
Ebner  (capillaries)  being  much  smaller,  the  irritation  is  not  so 
intense  nor  is  the  effect  of  pressure  or  chemical  changes  upon 
the  surrounding  bone  so  great.    The  area  of  absorption,  there- 


120  INTERSTITIAL    GINGIVITIS, 

fore,  is  limited,  resulting  in  small  canals  from  one  Haversian 
canal  to  another  or  from  one  absorbed  area  by  halisteresis  to 
another.  The  tissue  around  the  artery  now  is  not  unlike  the 
soft  tissue  previously  under  consideration  and  the  natural  proc- 
esses of  inflannnation  continue.  In  many  patients  the  process  of 
inflammation  stops  with  the  absorption  of  bone.  The  tooth  or 
teeth  now  are  simply  attached  to  normal  fibrous  tissue.  In  many, 
the  inflammatory  process  proceeds  a  little  further.  There  is 
now  acceleration  of  the  blood  stream  which  later  slows  consid- 
erably. The  central  stream  of  corpuscles  broadens  and  the  outer 
zone  of  plasma  grows  smaller  and  smaller.  The  same  process 
takes  place  in  reference  to  leucocytes,  red  l)lood  corpuscles  and 
exudate  as  before  (Fig.  31)  and  if  there  is  sufficient  irritation 
and  infection,  an  abscess  will  form  in  the  matrix  or  fibrous  tissue 
which  originally  contained  bony  tissue.  It  will  be  seen,  there- 
fore, that  the  rigid  bony  framework  of  tissue  prevents  great 
vascular  dilatation  without  bone  absorption.  It  may,  however, 
be  the  seat  of  great  pain,  due  to  pressure  of  the  confined  exudate 
upon  nerve  endings. 

Local  changes  in  function  such  as  want  of  proper  articula- 
tion; too  great  pressure  in  mastication  on  one  or  more  teeth: 
slight  change  in  position  of  teeth  after  they  have  once  become 
solid  in  the  jaw;  destroying  pulps  and  filling  roots  so  that  the 
peridental  membrane  is  required  to  do  more  work ;  hypertrophies 
of  roots ;  teeth  that  have  once  been  abscessed  and  were  appar- 
ently restored  to  health,  etc.,  are  a  few  of  the  local  causes  which 
earlier  set  up  inflammation  in  the  alveolar  process  by  the  irri- 
tants and  poisons  in  the  blood  stream  than  in  the  normal  adjoin- 
ing teeth. 

Local  irritations  such  as  wedging  of  teeth  for  filling;  correct- 
ing irregularities  of  the  teeth,  etc.,  which  have  already  set  up 
local  inflammation  are  fruitful  sources  and  weak  localities  for 
the  irritations  in  the  blood  stream  to  quickly  renew  inflamma- 
tion and  destruction  of  the  alveolar  process. 

One  of  the  best  illustrations  of  the  eifect  of  poisons  in  the 
blood  acting  upon  weak  abnormal  structures  in  the  jaw  is  that 
of  phosphorus  poisoning.  It  is  known  that  persons  working  in 
phosphorus,  such  as  match-making,  are  liable  to  phosphor  ne- 


INTEESTITIAL    GINGIVITIS.  121 

crosis  of  the  jaws.  When  it  occurs,  it  is  usually  associated  with 
a  carious  or  diseased  tooth.  It  is  supposed  that  the  phosphorus 
enters  the  jaw  through  or  around  the  tooth.  This,  however,  is 
not  the  case.  The  poisons  circulating  in  the  air  are  taken  into 
the  system  through  the  lungs  or  if  handled  by  the  hands  through 
the  skin.  It  thus  enters  the  blood  and  causes  a  general  disturb- 
ance of  nutrition.  The  blood  vessels  become  charged  with  the 
poison  and  the  taking  in  of  oxygen  is  considerably  diminished. 
In  consequence,  degeneration  of  tissues  results.  The  red  blood 
corpuscles  change  their  color  and  break  down.  The  nervous  sys- 
tem, especially  the  peripheral  nerves  degenerate.  The  arteries 
in  the  alveolar  process  are  the  first  to  become  diseased.  The 
parts  of  the  jaw  which  first  feel  the  effect  of  the  poison  are  those 
parts  where  the  teeth  have  lost  their  normal  function,  more 
particularly  teeth  with  dead  pulps  whose  roots  may  or  may  not 
be  filled,  with  or  without  slight  inflammation,  teeth  which  have 
abscessed  or  been  wedged  or  are  doing  more  work  than  normal. 

When  absorption  has  taken  place,  the  bone  is  not  restored 
after  the  person  has  obtained  his  growth,  the  transitory  nature 
of  the  process  and  only  two  sets  of  teeth  being  natural  to  man. 
If  the  process  be  removed  from  any  cause  (even  if  the  perma- 
nent teeth  be  still  in  the  jaw)  it  is  not  restored. 

The  absorption  of  the  alveolar  process,  under  constitutional 
causes,  usually  begins  at  the  gingival  border  because  of  its  thin- 
ness of  structure.  The  gum  tissue  does  not  change  but  follows 
the  bone,  in  its  absorption,  until  the  tooth  is  exfoliated  or  until, 
under  treatment,  the  alveolar  process  is  restored  to  health,  when 
the  gum  attaches  itself  firmly  to  the  bone  and  is  restored  to  its 
normal  condition. 

We  have  shown  the  simple  process  of  inflammation  to  the  for- 
mation of  abscess  and  the  absorption  of  bone  in  relation  thereto 
in  the  milder  forms  due  to  traumatism,  toxins  and  poisons,  but 
the  procedure  under  severe  constitutional  conditions  is  much 
more  intense. 

The  transitoiy  nature  of  the  alveolar  process,  its  sensitive- 
ness as  an  end  organ,  when  inflammation  is  once  set  up  in  the 
gums,  alveolar  process  or  peridental  membrane,  due  to  either 
local  or  constitutional  causes,  compels  it  to  become  chronic  with 


122  INTERSTITIAL    GINGIVITIS. 

disastrous  results  which  are  difficult  of  treatment  and  of  restora- 
tion to  health,  especially  if  the  vitality  of  the  patient  is  low. 
This  inflammatory  process  is  along  the  line  of  least  resistance. 

THE  NERVOUS  SYSTEM  IN  INFLAMMATION. 

There  is  much  discussion  by  certain  writers  in  regard  to  the 
action  the  nervous  system  plays  in  inflammation.  Some  take 
the  stand  that  the  central  nervous  system  does  act  upon  the 
blood  vessels  in  a  given  locality  while  others  claim  that  it  must 
be  a  peripheral  nervous  mechanism  which  controls  the  blood  ves- 
sels. Experiments  have  shown  that  the  vascular  changes  con- 
nected with  inflammation  can  occur  independently  of  the  central 
nervous  system.  It  follows  then  that  there  may  be  a  peripheral 
nervous  mechanism  controlling  the  vessels. 

It  has  been  demonstrated  by  Klebs  ^  that  the  endothelial  walls 
of  the  capillaries  do  contract.  The  conclusion  then  is  that  the 
endothelium  of  the  capillaries  is,  to  some  extent,  self  regulating. 
It  is  quite  possible  that  the  muscular  coats  of  the  smaller  ar- 
teries and  capillaries  act  to  stimuli. 

Thoma  -  says,  ''It  is  evident,  however,  that  the  local  circula- 
tory reaction  after  injury  depends  upon  the  condition  of  the 
cerebro-spinal  vasomotor  centers  and  that  the  peripheral  vaso- 
motor nerve  apparatus  may  also  act  independently.  From  what 
has  been  said  it  appears  that  among  the  direct  action  of  trau- 
matism, injury  to  the  nerves  is  of  great  importance.  This  injury 
to  the  nerves  at  the  site  of  the  lesion  is  either  a  change  in  the 
invisible  molecular  structure  of  the  nerve  fibers,  or  one  which 
can  be  recognized  under  the  microscope.  Each  change  in  the 
molecular  structure  of  the  nerve  causes  a  change  in  its  excitabil- 
ity which  is  termed,' nerve  irritation'  by  physiologists.  This  irri- 
tation is  frequently  more  or  less  painful,  and  is  perceived  sub- 
jectively as  pain.  The  disturbance  of  the  innervation  of  the 
vessel  wall,  however,  is  to  be  clearly  distinguished  from  the  sen- 
sation of  pain.  The  former  also  is  partly  caused  by  the  direct 
action  of  the  injury  to  the  vasomotor  nerv   apparatus  contained 


1  Klebs.    AUg.  Pathologie. 

"  Thoma.     Pathology  and  Pathological  Anatomy. 


THE   NERVOUS   SYSTEM   IX   IXFLAMMATIOX,  123 

in  the  injured  area.  The  distnrbance  of  vasomotor  innervation, 
however,  is  seldom  strictly  limited  to  the  area  directly  affected 
by  the  injury,  since  the  nerve  irritation  both  directly  and  re- 
flexly  alters  the  excitability  of  the  vasomotor  centers  in  the  walls 
of  the  neighboring  arteries,  and  thus  causes  the  local  circulators- 
reaction.  ' ' 

My  researches  have  shown  that  the  nerve  supply  in  the  alveo- 
lar process,  as  compared  with  that  in  the  peridental  membrane 
and  periosteum  is  very  slight.  Inflanunation  and  infection, 
therefore,  taking  place  in  the  peridental  membrane  at  the  apical 
end  of  the  tooth  root  forming  alveolar  abscess  or  at  the  side 
nearest  to  the  apical  end  where  peridental  abscess  forms,  where 
the  alveolar  wall  is  quite  thick,  pain  is  much  more  severe  than 
when  the  abscess  forms  in  or  near  the  gingival  margin  of  the 
process.  On  account  of  local  and  constitutional  irritations, 
nerve  end  degeneration  in  alveolar  absorption  is  the  rule.  Pain, 
however,  in  this  instance  is  not  as  severe  in  abscess  formation  in 
the  alveolar  process  as  in  other  bones. 

These  local  and  constitutional  irritations  produce  paralysis 
and  finally  death  of  the  nerve  fiber.  When  degeneration  or  death 
of  the  nerve  fiber  takes  place,  the  action  upon  the  coats  of  the 
arteries  is  such  that  inflammation  and  absorption  of  the  alveolar 
process  ensues. 

The  local  irritations  and  infections  produce  the  same  effect 
upon  tissue  in  inflammation  as  the  internal  (constitutional)  irri- 
tations and  infections.  Adami  •'  says,  ''Anything  which  causes 
local  injury  to  the  tissue  is  a  cause  of  inflammation,  be  it  a  me- 
chanical trauma,  a  physical  insult,  as  by  heat,  cold  or  electricity, 
a  disturbance  brought  about  by  altered  metabolism  and  abnor- 
mal internal  secretions,  or  bacterial  or  microbic  invasion  and 
growth.  This  last  is  the  commonest  cause  of  acute  reaction  and 
differs  from  the  physical  and  mechanical  causes  (although  not 
from  metabolic  disturbances)  in  that,  as  a  cause,  it  is  not  of 
momentary  duration,  but  of  continued.  It  is  not  the  mere  physi- 
cal entry  of  microbes  into  the  tissues  that  induces  inflammation 
but  the  liberation  of  them  of  their  products  in  growth  or  disin- 
tegration.   And  so  long  as  those  products  are  being  liberated. 


■  Adami.     Principles  of  Pathology,  Vol.  I,  page  420. 


124  INTERSTITIAL    GINGIVITIS. 

for  SO  long  is  the  cause  of  action.  It  differs  from  the  metabolic 
causes  in  that  the  latter  induce  tissue  irritation  of  a  milder  grade 
and  do  not  induce  acute,  but  rather  chronic  reaction." 

Kirk''  says,  "Viewed  as  an  inflammatory  process  we  have, 
then,  in  the  study  of  pyorrhoia  (interstitial  gingivitis)  to  regard 
its  clinical  or  objective  phenomena  as  reactions  of  the  retentive 
tissues  of  the  teeth  toward  injuries  inflicted  by  mechanical 
trauma,  physical  irritants,  altered  metabolism,  the  toxic  effects 
of  altered  secretions,  or  by  the  toxic  products  of  microbic  or 
bacterial  invasion.  Any  of  these  agencies,  severally  or  collec- 
tively, ma}^  induce  such  changes  in  the  retentive  structures  as 
will  lead  to  their  molecular  necrosis  and  the  ultimate  exfoliation 
of  the  teeth,  the  process  constituting  comprehensively  what  we 
know  as  pyorrhoea  alveolaris  (interstitial  gingivitis)." 

The  process  of  inflammation  from  local  irritation  and  infec- 
tion proceeds  in  the  same  manner  as  the  traumatism  upon  the 
web  of  the  frog's  foot. 

Patients  who  have  been  ill  for  any  length  of  time,  such  as 
those  suffering  with  phthisis,  lues,  kidney  lesions  or  other  linger- 
ing diseases,  and  those  with  low  vitality,  take  on  interstitial  gin- 
givitis much  more  readily  than  those  of  strong  vitality. 

Summing  up  this  chapter,  no  matter  whether  the  irritation 
be  local  or  constitutional  or  both,  the  inflammation  set  up  thereby 
is  progressive  in  its  nature  and  does  not  cease  until  the  tooth 
or  teeth  have  been  exfoliated  by  the  absorption  of  the  alveolar 
process,  although  treatment,  changes  in  environment  and  sys- 
temic conditions  may  check  the  disease  for  a  limited  time.  The 
inflammation  is  solely  the  cause  of  bone  absorption  and  may  be 
slow  or  rapid  in  its  action. 


*  American  Text-Book  of  Operative  Dentistry,  Fourth  Edition,  page  470. 


CHAPTER  XIV. 

RESEARCHES    OX    AXIMALS    IX    IXTERSTITIAL    GIXGIVITIS. 

All  vertebrates  possessing  two  sets  of  teeth  during  life 
the  roots  of  which  are  situated  in  bony  sockets  have  interstitial 
gingivitis  to  a  greater  or  lesser  extent.  The  mere  fact  of 
the  eruption  and  shedding  of  the  teeth,  as  in  human,  is  an 
indication  that  there  is  an  inflammatory  process  present.  Wild 
animals  leading  a  natural,  normal  hfe  are  less  liable  to  have 
this  disease  than  those  having  become  domesticated.  Wild 
animals  domesticated  and  tamed  animals  taken  out  of  their 
natural  environment  suffer  with  this  disease  to  as  marked  a 
degrees  as  human.  While  it  is  true  animals,  as  a  rule,  do  not 
suffer  with  the  nervous  types  of  disease  like  human,  yet  a  wild 
animal  in  confinement  with  artificial  feeding  must  suffer,  to 
a  greater  or  lesser  extent,  according  to  the  nature  of  the  change 
and  the  amount  of  restlessness  produced.  Changes  in  vital 
resistance  are  not  as  frequent  or  as  marked  in  animals  as  in 
human,  yet  wild  as  well  as  domesticated  animals  do  occasion- 
ally suffer  with  disease  and  changes  in  vital  resistance. 

Wild  animals  roaming  at  large  and  obtaining  their  food 
are  in  a  much  more  natural  environment  than  when  in  captiv- 
ity. The  organs  of  the  body  are  performing  their  natural 
functions,  and  thus  elimination  is  carried  on  normally.  Old 
age,  even  in  animals  living  in  their  natural  wild  environment, 
predisposes  weakened  eliminating  organs,  wdiile  these,  in  turn, 
owing  to  poisons  in  the  blood,  will  cause  interstitial  gingivitis 
and  finally  loss  of  teeth. 

Wild  animals  under  domestication  OA\^ng  to  change  of  emd- 
ronment  can  best  be  studied  in  relation  to  this  disease.  A  visit 
to  the  great  Zoological  Gardens  in  Dublin,  London,  Hamburg, 
Paris,  New  York  City  or  Chicago,  and  a  careful  study  of  the 
mouths  and  jaws  of  the  animals  there  confined  will  readily 
convince  the  investigator  of  the  truth  of  these  statements. 
Monkeys  are  probably  more  susceptible  to  disease  and  death 


126 


INTERSTITIAL    GINGIVITIS. 


than  most  animals.  Cows  fed  upon  brewers'  slop  and  con- 
fined indoors  have  interstitial  gingivitis  badly;  horses  which 
have  been  biting  grass  with  their  front  teeth,  living  in  the  sun- 
shine and  breathing  the  fresh  air,  when  returned  to  the  stable  in 
the  Fall  begin  to  ''crib,"  biting  the  woodwork  around  the 
stall.  The  front  teeth  feel  uncomfortable  because  of  the  entire 
change  of  environment.  The  "cribbing"  causes  the  blood  to 
be  forced  out  of  the  capillaries  of  the  peridental  membrane, 
and  for  the  time  being  gives  relief  to  the  animal.  It  soon 
returns  and  because  of  the  pain  the  process  is  repeated.  In 
the  course  of  a  week  or  two,  however,  the  eliminating  organs 
adjust  themselves  to  the  new  environment  and  the  teeth  remain 
comfortable.  House  animals  are  very  prone  to  interstitial 
gingivitis  as  well  as  to  other  constitutional  diseases.  In  most 
animals  of  this  kind  they  are  taken  out  of  their  natural  envi- 
ronment, and  autointoxication  and  disease  is  the  rule.  The 
carnivora  suffer  with  pyorrhoea  alveolaris  to  a  more  marked 
extent  than  the  herbivora  owing  to  the  fact  that  they  subsist 
to  a  great  degree  upon  pus-ladened  nitrogenous  food,  thus 
infecting  the  gums  and  peridental  membrane.  Dogs  with  this 
disease  are  the  best  animals  for  research. 

As  the  first  step  in  investigation,  two  practitioners  of 
comparative  medicine,  with  an  extensive  hospital  practice 
(Dr.  Charles  E.  Sayre  and  Dr.  Alsop  E.  Flower),  were  con- 
sulted as  to  the  frequency  of  this  disease  in  animals.  All 
animals  under  their  care  suffered  from  it  more  or  less,  but 
eighty  per  cent  of  dogs  over  eight  years  of  age  had  the  dis- 
ease. Nearly  every  dog  in  the  hospital  under  their  care  was 
so  affected.  These  dogs  comprised  all  breeds,  from  spaniels 
and  terriers  to  the  Newfoundland,  St.  Bernard  and  great  Dane. 
On  examination,  every  phase  of  interstitial  gingivitis  was  found 
in  the  mouths  of  these  dogs,  from  its  inception  to  the  loss  of 
the  teeth.  The  number  of  dogs  observed  was  twenty-seven. 
The  roots  of  the  teeth  of  some  were  covered  with  deposits 
and  so  exposed  that  the  teeth  could  be  removed  with  the  fin- 
gers. Such  diseased  mouths  are  rarely,  if  ever,  present  in 
human  beings.  The  outer  plate  of  bone  was  absorbed,  the  roots 
entirely  exposed,  pus  was  oozing  from  around  them  and  the 
mucous  membrane  was  badly  inflamed. 


EESEAECHES    ON    ANIMALS    IN    INTERSTITIAL    GINGIVITIS.  127 

It  should  be  remembered  tliat  the  jaw  of  the  dog,  like  the 
jaw  of  man,  is  undergoing  considerable  variation.  Like  man, 
the  dog,  having  put  liimself  under  new  social  conditions  (so 
to  speak),  is  varying  greatly  both  as  to  brain,  skull  and  jaw 
from  his  wolf-like  ancestor.  As  he  is  under  the  protection  of 
man,  the  struggle  for  existence  as  to  food  is  less  intense  than 


F:g.  32. — The  Mouth  of  a  Scotch  Terrier,  Some  of  the  Teeth  Have  Been  Re- 
moved ON  Account  of  Interstitial  Gingivitis. 

in  the  wild  state  and  consequently  there  is  less  occasion,  even 
for  fighting  purposes,  of  his  jaws  and  teeth. 

Independently  of  conditions  of  this  type,  many  of  the  dogs 
suffered  from  constitutional  disorders.  Eight  had  skin  dis- 
eases which  in  the  dog  are  more  likely  to  produce  obvious  con- 


128 


INTERSTITIAL    GINGIVITIS. 


stitutional  defects  than  in  man.  Some  were  old  and  blind. 
Some  had  been  injured  and  were  under  treatment  for  wounds. 
Some  were  suffering  from  rachitis,  nervous  diseases,  and  were 
overbred.  Others  were  constipated  or  had  germ  types  of  diar- 
rhoea.    One  had  kidney  inflammation  and  bronchitis  with  high 


Fig.  33. — The  Mouth  of  a  Boston  Terrier;  Owing  to  Illness  Interstitial  Gingi- 
vitis HAS  Caused  Absorption  of  Bone  and  the  Incisors  and  Molar  were 
Removed  by  the  Fingers. 


fever.     In  short,  these  dogs,  being  house  dogs,  presented  most 
of  the  constitutional  diseases  to  which  man  is  liable. 

The  mouth  of  a  Scotch  terrier  is  shown  in  Fig.  32.  The 
molar  and  premolar  had  been  removed  with  the  fingers.  The 
cuspids  and  incisors  are  quite  loose.     There  are  large  deposits 


KESEAECHES    ON    ANIMALS    IN    INTERSTITIAL    GINGIVITIS. 


129 


of  tartar.  The  gum  and  alveolar  process  have  been  absorbed 
nearly  one-half  the  length  of  the  roots  of  the  teeth.  In  Fig.  33 
is  seen  the  mouth  of  a  Boston  terrier  with  the  incisors .  and 
premolars  removed.  There  is  extensive  pyorrhoea.  There  are 
calcic  deposits  upon  the  cuspids  and  molars.  There  is  recession 
of  the  gums  and  alveolar  process.    In  Fig.  34  is  shown  the  mouth 


Fig.  34. — The  Mouth  or   Another   Boston    Terrier;    One  Tooth   has   been   Re- 
moved AND  Interstitial  Gingivitis  is  Seen  Around  the  Other  Teeth. 


of  another  Boston  terrier.  In  it  one  premolar  in  the  upper  and 
one  on  the  lower  jaw  have  been  extracted.  There  is  extensive 
inflammation  of  the  gum  about  the  molar,  cuspid  and  incisor 
with  large  calcic  ileposits  about  the  teeth.  In  Fig.  35  are  shown 
teeth  covered  with  calcic  deposit  the  entire  length  of  the  root. 


130  INTERSTITIAL    GINGIVITIS. 

These  teeth  were  removed  by  the  fingers  from  the  mouths  of  two 
dogs,  one  of  which  was  later  obtained  for  scientific  study.  This 
was  all  the  material  to  be  obtained  from  the  hospital,  since  the 
dogs  were  pets  which  had  been  placed  under  treatment  by  their 
owners. 

Through  the  courtesy  of  Poundmaster  Hugh  Curran,  the 
necessary  material  was  obtained  from  the  Chicago  Dog  Pound. 
Here  from  four  hundred  to  a  thousand  dogs  are  killed  per  week 
during  June,  July  and  August  each  year.  Ninety-five  per  cent 
are  mongrel  curs  leading  a  street  life,  hence  neither  luxurious 
diet  nor  luxurious  care  can  be  charged  with  any  disease  in 
them.  They  have,  at  least,  i)lenty  of  outdoor  exercise  and  fresh 
air.  Many,  despite  this  reversion  to  the  life  of  their  wolflike 
ancestors,  have  skin  diseases  and  are  deaf  and  blind  from  old 
age.    The  bodies  were  secured  after  death,  at  which  time  exam- 


Fjg.  35. — Shows  Teeth  of  a  Dog  Covered  -with  Cah!K'  Deposits  which  were  Quite 
Loose  and  were  Eemoved  by  the  Fingers. 

inations  of  the  mouths  were  made.  Five  per  cent  of  the  dogs 
entering  the  pound  are  of  good  breeds.  These,  if  not  called  for 
by  the  owners,  are  sold  for  a  moderate  price. 

The  dogs  selected  for  the  death  penalty  are  collected  in  a 
large  box  pen,  leading  out  of  which  is  a  door  through  which  they 
pass  into  an  air-tight  box.  Communicating  with  this  box  is  a 
stove  in  which  sulphur  is  burned  with  charcoal.  The  fumes 
pass  into  the  box  and  death  is  almost  instantaneous  and  painless. 
After  they  remain  fifteen  minutes,  a  door  leading  to  the  air  is 
opened  and  the  bodies  are  carted  away.  It  was  at  this  time  that 
access  was  had  to  them.  The  mouths  were  then  examined.  Such 
cases  as  were  of  interest  were  placed  on  one  side  and  the  jaws 
removed  from  the  bodies.  Inside  of  one-half  hour  the  specimens 
were  in  a  solution  to  be  kept  until  desired  for  use.  Jaws  (with 
interstitial  gingivitis  in  all  stages  of  progress,  from  simple  in- 


EESEARCHES    OX    ANIMALS    IX    INTERSTITIAL    GIXGIVITIS.  131 

Haiiimation  of  the  g-iims  to  the  most  extreme  cases  of  exfoliation 
of  the  teeth)  were  obtained  in  an  abundance  for  future  studies. 
It  is  not  an  easy  matter  to  ascertain  the  ages  of  these  animals. 
In  a  general  way,  it  was  found  that  inflammation  of  the  gums, 
especially  about  the  canine  teeth,  was  almost  always  present  in 
dogs  over  one  year.  About  twenty  five  per  cent  of  these  dogs  at 
four  years  of  age  had  the  disease,  eighty  per  cent  at  from  eight 
to  ten  years,  ninety-five  per  cent  over  twelve  years  of  age. 
Since  I  commenced  my  investigation  (twenty  years  ago),  I  have 
examined  quite  a  large  number  of  dogs  about  homes,  but  have 
never  found  a  dog"  over  four  years  without  this  disease  to  a 
greater  or  less  extent.  Many  house  dogs  at  one  year  had  inflam- 
mation of  the  gums.  Dogs  for  infection  and  those  used  for  mer- 
curialization  were  picked  up  in  the  streets. 

Most  of  the  dogs  exhibited  at  dog  shows  are  young,  ranging 
from  one  to  four  years  of  age.  About  twenty-five  per  cent  would 
range  four  years  to  eight.  A  casual  examination  of  their  mouths 
revealed  interstitial  gingivitis.  Occasionally  recession  of  the 
gums  and  pyorrlioea  alveolaris  occurred.  On  a  more  careful  ex- 
amination, twenty-five  per  cent  of  dogs  between  the  ages  of  one 
and  four  were  found  to  have  interstitial  gingivitis  and  seventy- 
five  per  cent  of  dogs  from  four  to  eight  years  were  found  to 
have  interstitial  gingivitis  with  recession  of  the  gums  and  pyor- 
rhoea alveolaris.  In  the  study  of  this  disease,  therefore,  dogs 
are  excellent  substitutes,  since  for  pathologic  research  they  can 
be  obtained  at  any  stage  of  the  disease. 

The  technique  of  the  examinations  of  interstitial  gingivitis 
and  pyorrhoea  alveolaris  in  dogs  was  as  follows:  After  fixing 
and  hardening  in  two  per  cent  formalin,  alcohol,  or  Muller's 
fluid,  the  tissues  were  decalcified  in  a  five  per  cent  alcoholic  solu- 
tion of  nitric  acid,  imbedded  in  celluloidin  and  stained  in  various 
Avays,  the  principal  ones  being  hgematoxylin  and  eosin.  Ten  or 
more  slides  would  be  obtained  from  each  tooth.  Out  of  these 
slides  have  been  selected  a  series  illustrating  the  progress  of  the 
disease  from  beginning  to  the  loosening  of  the  tooth. 

Fig.  36  is  a  longitudinal  section  of  a  cuspid  tooth  A\ith  the 
alveolar  process  in  situ.  A  illustrates  the  enamel  of  the  tooth, 
(E)  the  epithelium  passes  from  the  outer  margin  to  the  lower 


X  75.     A.  A.  obj.     Zeiss.     Micro-photograph,  reduced  one-third. 

Fig.  36. — Longitudinal  Section  of  Tooth  and  Gum  Tissue.   Slight  Gingivitis.    Dog. 

A,  Enamel.     E,  Epithelial  Tissue.     G,  Submucous  ■Membrane.     M,  Filirous  Tissue. 
SI,  Slight  Inflammation. 


X  75.     A.  A.  obj.     Zeiss.     Micro-photograph,  reduced  one-third. 

Fig.  37. — Longitudinal  Section  op  Tooth  and  Gum  Tissue.    Chronic  Interstitial 

Gingivitis.     Dog. 

A.  Enamel.  E.  Epithelial  Tissue.  G,  Submucous  Membrane.  H.  Periosteum. 
K,  Capillaries.  'V'.  ^'folent  Inflammation.  AA,  Point  of  I''^nion  of  Epithelial  Tissue 
and  Peridental  Membrane.    ER,  Space  Pocket  from  want  of  Union  of  Epithelial  Fold. 


X  75.     A.  A.  obj.     Zeiss.     Micro-photogTaph,  reduced  one-third. 

Pig.  38. — Longitudinal  Section  of  Alveolar  Process  and  Peridental  Membrane. 
Slight  Interstitial  Gingivitis,  Extending  into  Alveolar  Process.     Dog. 

J,  Alveolar  Process.     U,  Inflammation  Extending  through  Enlarged  Haversian  Canals. 
I^,  Inflamed  Peridental  Membrane. 


X  75.     A.  A.  obj.     Zeiss.     Micro-photograph,  reduced  one-third. 

Fig.  39. — Loxgitudinal'Gection  of  Alveolae  Process  and  Peridental  Membrane. 
Chronic  Interstitial  Gingivitis,  Extending  into  Alveolar  Process.     Dog. 

H,  Periosteum.  J,  Alveolar  Process.  V,  Violent  Inflammation.  AA,  Point  of 
Union  of  Epithelial  Tissue  and  Peridental  Membrane.  1\  Inflamed  Peridental  Mem- 
brane.   L^,  Inflammation  Extending  through  Enlarged  Haversian  Canals. 


136  INTERSTITIAL    GINGIVITIS. 

border,  then  folds  upon  itself  and  extends  down  tlie  side  of  the 
crown  of  the  tooth  as  far  as  the  neck.  Unfortunately,  in  this 
specimen,  the  structure  connecting  the  epithelium  and  the  fibrous 
tissue  of  the  periosteum  has  been  destroyed.  The  papillary  layer 
of  the  sub-epithelial  tissue  is  plainly  shown  at  the  outer  border. 
Small  round-cell  inflammation  may  be  seen  extending  along  the 
border  of  this  layer.  It  can  also  be  observed  extending  do\vn 
the  capillary  blood  vessels  into  the  submucous  tissue  (SI  and  Gr). 

Fig.  37  shows  a  similar  section  of  another  tooth.  Here  the 
epithelial  structure  (E)  is  pulled  away  slightly  from  the  edge  of 
enamel  (A).  In  this  section  the  infolding  of  the  epithelium  is 
shown  at  the  neck  of  the  tooth.  This  structure  passes  dow^nward, 
folds  outward  and  upon  itself  (AA)  and  returns  two-thirds  of 
the  distance  toward  the  gingival  border,  leaving  a  pocket  (RR). 
The  epithelium  (E)  is  very  dense  and  thick.  The  papillary 
layer  of  the  submucous  tissue  (G)  is  very  clearly  defined.  The 
capillaries  (K)  can  be  distinctly  traced  from  the  deeper  fibrous 
tissue  through  the  submucous  layer  into  the  papillary  layer. 
The  thick  and  heavy  fibrous  tissue  of  the  periosteum  ("Dental 
Ligament,"  Black)  may  be  seen  at  H,  inserted  firmly  into  the 
cementum  and  extending  outward  and  downward.  Just  below 
(A A)  may  be  seen  the  interlacing  of  the  coarser  fibers  of  the 
periosteum  with  the  finer  fibers  of  the  submucous  tissue.  Chronic 
round-cell  inflammation  may  be  seen  extending  from  the  papil- 
lary layer  through  the  capillaries  into  the  interstitial  tissue  of 
the  subnuicous  layer  and  the  periosteum.  Marked  inflammation 
has  occurred  at  V.  The  openings  in  the  folds  of  the  epithelium 
are  fruitful  sources  for  the  accumulation  of  food,  epithelial 
scales  and  detritus,  in  which  fermentation  and  decomposition 
from  micro-organisms  result,  producing  inflammation. 

Fig.  38  is  a  section  through  the  peridental  membrane  (I)  and 
alveolar  process  (J)  at  the  lateral  incisor.  The  inflammation 
has  extended  down  from  the  papillary  layer  through  the  sub- 
mucous tissue,  the  fibrous  tissue  of  the  periosteum  into  the  peri- 
dental membrane  and  into  the  alveolar  process.  Round-cell  in- 
flammation may  be  seen  in  the  blood  vessels  extending  through 
the  Haversian  canals  (L^). 

Fig.  39  is   a   similar   section  from  another  tooth   showing 


KESEARCHES    ON    ANIMALS    IN    INTERSTITIAL    GINGIVITIS.  137 

chronic  inflammation  extending  throughout  the  peridental  mem- 
brane (I)  and  alveolar  process  (J).  The  Haversian  canals  (L) 
are  well  outlined  by  the  inflammatory  progress.  Marked  inflam- 
mation has  resulted  at  V  and  also  at  the  margin  of  the  alveolar 
process. 

Fig.  40  is  a  section  of  the  peridental  membrane  and  alveolar 
process,  illustrating  the  effect  of  interstitial  inflammation  upon 
the  blood  vessels  and  alveolar  process.  Chronic  inflammation 
extends  throughout  the  peridental  membrane  with  very  decided 
inflammatory  change  (V).  The  cut  ends  of  the  blood  vessels 
which  were  originally  situated  in  the  Haversian  canals  are  seen 
(BV).  They  have  become  involved  with  the  result  of  a  thicken- 
ing of  the  walls  and  endarteritis  obliterans.  The  bone  about 
these  vessels  has  been  entirely  absorbed.  The  inflammation 
has  extended  beyond,  into  and  througli  the  Haversian  canals, 
producing  the  type  of  absorption  of  the  trabeculae  known  as 
halisteresis  ossium.  Lacunar  absorption  has  also  occurred  (0). 
Where  decided  inflammation  (V)  has  taken  place,  abscesses  are 
more  liable  to  occur  (as  will  be  noticed  later)  from  the  large 
number  of  blood  vessels  at  this  locality. 

Fig.  41  is  a  section  from  another  location  of  the  alveolar 
process  with  a  greater  amplification,  showing  the  inflammatory 
process  extending  through  the  alveolar  process.  Endarteritis 
obliterans  may  be  seen  in  different  locaUties  (EO) .  Three  forms 
of  absorption  are  evident  in  this  figure  :  Enlarged  areas  arising 
from  absorption  of  the  trabeculae  (halisteresis  ossium)  due  to  the 
inflammatory  process.  The  vessels  of  Von  Ebner  precede  per- 
forating canal  absorption  (BB),  distributed  over  the  entire  field, 
also  the  result  of  the  inflammatory  process  and  lacunar  absorp- 
tion (0)  which  may  result  from  inflammation.  As  long  as  the 
fibrous  tissue  remains  in  these  large  areas  to  retain  the  osteo- 
blasts, new  bone  tissue  may  be  produced  under  favorable  condi- 
tions. On  the  other  hand,  when  this  tissue  and  the  osteoblasts 
are  destroyed,  the  alveolar  process  cannot  be  restored. 

Fig.  42  shows  a  section  of  the  alveolar  process  from  another 
dog.  Here  lacunar  and  other  absorption  (halisteresis  ossium) 
are  well  shown.'  Thirty-seven  osteoclasts  (0)  may  be  counted  in 
the  field  while  destruction  of  bone  by  halisteresis  (Q)  is  rapidly 


138  INTERSTITIAL    GINGIVITIS. 

going  on.  Remains  of  Haversian  canals  with  the  blood  vessels 
may  be  seen  (BV,  L).  In  the  discussion  of  the  peridental  mem- 
brane extending  into  the  alveolar  process  (page  37),  particular 
attention  was  called  to  the  fact  that  large  bundles  of  fibers  ex- 
tended into  the  process  in  such  a  manner  as  almost  to  isolate 
portions  of  bone.  In  the  lower  left-hand  corner  (X)  may  be 
seen  two  pieces  of  the  alveolar  process  entirely  separated  from 
each  other  and  the  main  body  of  the  bone.  In  interstitial  gingi- 
vitis, it  is  not  uncommon  to  find  pieces  of  the  alveolar  process 
separated  by  halisteresis  and  lacunar  absorption.  When  loose 
teeth  are  extracted  as  a  result  of  this  disease,  pieces  of  the  alveo- 
lar process  come  away  with  the  peridental  membrane  attached  to 
the  tooth.  Fig.  89  was  obtained  in  this  manner.  In  the  upper 
left-hand  corner  may  be  seen  eight  or  ten  new  osteoclasts  (0) 
in  an  enlarged  Haversian  canal,  at  work  isolating  one  piece  of 
the  alveolar  process  from  the  other. 

Fig.  43  shows  a  slide  from  still  another  dog.  Halisteresis 
(Q)  and  perforating  canal  (P)  absorption  are  here  well  shown. 
In  the  larger  space  at  the  lower  left-hand  corner  may  be  seen 
two  arteries  (EO)  which  w^ere  originally  the  location  of  Haver- 
sian canals  and  which  have  thickened  walls  and  a  tendency  to 
obliteration.  The  light  color  shows  decalcification,  the  dark  nor- 
mal bone.  At  P  may  be  seen  perforating  canal  absorption.  At 
FG  fat  globules  may  be  seen,  while  in  the  larger  space  at  the 
upper  right-hand  corner  is  evident  entire  destruction  of  the 
fibrous  tissue. 

Fig.  44  illustrates  a  cross  section  of  alveolar  process  and 
cuspid  root,  showing  absorption  of  the  root.  Inflammation 
extends  throughout  the  peridental  membrane  (I).  The  capil- 
laries (K)  are  quite  numerous.  These  are  cut  both  crosswise 
and  lengthwise.  Absorption  (S)  of  the  root  may  be  seen  pro- 
gressing at  these  localities. 

Fig.  45  shows  a  longitudinal  section  of  the  end  of  the  root. 
Active  destruction  has  been  going  on  both  in  the  pulp  chamber 
(D)  and  at  the  external  surface  of  the  cementum  (C).  The  irri- 
tation and  inflammation  has  caused  the  odontoblasts  to  "fill  up 
the  pulp  chamber  with  secondary  dentine,  and  obliteration  of  the 
chamber  has  taken  placo.     Below  the  constricted  pulp  may  be 


X  75.     A.  A.  obj.     Zeiss.     Micro-photograph,  reduce. 1  oue-thint. 

Fig.  40. — LoxGiTUDixAL  Section  of  Tooth,  Alveolar  Process  and  Peridental  Mem- 
brane. VlOfcENT  EOUND-CeLL  INFLAMMATION  OF  PERIDENTAL  MEMBRANE,  EX- 
TENDING THROUGH  THE  HAVERSIAN  CaNALS  INTO  THE  ALVEOLAR  PROCESS. 

C,  Cementum.  J,  Alveolar  Process.  K,  Capillaries.  L,  Haversian  Canals.  N,  Large 
Spaces  arising  frohi  Absorption  of  the  Trabeculae,  starting  in  the  Haversian  Caj-als 
(Halistere«;is).  O,  Lacunar  Absorption.  V,  Violent  Intlamnitttion.  BV,  Blood 
Vessels,  originally  Haversian  Canals.  I^,  Inflamed  Peridental  Membrane.  L^,  Inflam- 
mation Extending  through  Enlarged  Haversian  Canals. 


X  150.     D.  U.  obj.     Zeiss.     Micro-photograph,  reduced  one-third. 
Fig.  41. — Longitudinal  Section  of  Alveolar  Process.    Chronic  Inflammation  Ex> 

TENDING  throughout,  SHOWING  HALISTERESIS,  PERFORATING  CANAL  AND  LACUNAR 

Absorption.     Dog. 

J,  Alveolar  Process.  N,  Large  Spaces  arising  from  Absorption  of  the  Trabeculae, 
starting  in  the  Haversian  Canals  (Halisteresis).  O,  Lacunar  Absorption.  P,  Perforat- 
ing Canal  Absorption.  BB,  Blood  Vessels  of  V.  Ebner  preceding  Perforating  Canals. 
EO,  Endarteritis  Obliterans. 


X  75.     A.  A.  obj.     Zeiss.     Micro-photograph,  rciliiced  one-third. 

Fig.  42. — Longitudinal  Section  of  Alveolar  Process.    Chronic  Inflammation  Ex- 
tending THROUGHOrT,  SHOWING  HaLISTERESIS  AND  LACUNAR  ABSORPTION.      DOG. 

J,  Alveolar  Process.  L,  Haversian  Canals.  N,  Large  Spaces  arising  from  Ab- 
sorption of  the  Trabecular,  starting  in  the  Haversian  Canals.  0,  Lacunar  Absorption. 
Q,  Halisteresis  Ossium  or  Decalcified  Bone.  X,  Remains  of  Calcified  Bone.  BV,  Blood 
Vessels  originally  Haversian  Canals. 


X  75.     A.  A.  obj.     Zeiss.     Micro-photograph,  reduced  one-third. 

Fig.  43. — Transverse  Section,   Alveolar  Process.     Chronic  Inflammation   Ex- 
tending THROUGHOUT.     DOG. 

J,  Alveolar  Process.  N,  Large  Spaces  arising  from  Absorption  of  the  Trabeculse, 
starting  in  the  Haversian  Canals.  P,  Perforating  Canal  Absorption.  Q,  Halisteresis 
Ossium  or  Decalcified  Bone.  X,  Eemains  of  Calcified  Bones.  EO,  Endarteritis  Obli- 
terans.    FG,  Fat  Globules. 


X  75.     A.  A.  obj.     Zeiss.     Micro-phot ograpli,  reduced  one-third. 

Fig.  44. — Cross  Section  of  Tooth,  Alveolar  Process  and  Peridental  Membrane. 
Chronic  lNFLA*fMATioN  of  Peridental  Membrane  and  Absorption  op  the 
Eoot  of  Tooth.     Dog. 

B,  Dentine.     C,  Cementuni.     D,  Pulp.     I\  Inflamed  Peridental  Membrane.     K,  Capil- 
laries.    S,  Eoot-absorption. 


i 


^■a: 


■'.'-    i':  .A. 


/.  "^'.^ 


X  75.     A.  A.  obj.     Zeiss.     Micro-photograph,  rediieed  one-third. 
Fjg.  45.— Lokgitudinal  Section  of  the  End  of  the  Root  of  a  Tooth    Alveolar 
Process  and  Peridental  Membrane,  Showing  Chronic  InflammaSon  op  the 
iB^OR^i    Dog'""'-     '''''™"''  °'  '^"^  ''''''  °^  ™^  tooth  ANrL^JuN^R 

C,  Cementum.     D   Pulp,  with  3  Poramina.     J,  Alveolar  Process.     O,  Lacunar  Absorp- 
tion.    P,  Perforating  Canal  Absorption.     CC,  Cementosis. 


X  75.     A,  A.  obj.     Zeiss.     Micro-photograph,  reduced  one-third. 

Fig.  46. — Cross  Section  of  Inflamed  Peridental  Membrane.     Dog. 

II,  Inflamed  Peridental  Membrane.    W,  Epithelial  Debris. 


X   15.     75   M.  M.  obj.     Spencer.     Micro- j)hotograpb,  reduced   one-third. 

Fig.  47. — Longitudinal  Section  of  Tooth,  Alveolar  Process,  Peridental  Mem- 
brane, Showing  Interstitial  Gingivitis  and  Pyorrhoea  Alveolaris,  with 
Tooth  About  to  be  Exfoliated.    Dog. 

C,  Cementnm.  E,  Epithelial  Tissue.  H,  Periosteum.  I,  Peridental  Membrane. 
J,  Alveolar  Process.  K,  Capillaries.  L,  Haversian  Canals.  M,  Fibrous  Tissue.  R, 
Pus  Pockets.  U,  Nerve  Tissue.  V,  Violent  Inflammation.  AA,  Point  of  Union  of 
Epithelial  Tissue  and  Peridental  Membrane.  GO,  Cementosis.  DD,  Calcific  Deposits 
Destroyed  by  Acids. 


X  40.     35  M.  M.  o])j.     Zeiss,     ^licro-photograph.  reduced  one-third. 

Fig.  48. — Longitudinal  Section  of  Tooth,  Alveolar  Process,  Peridental  Mem- 
brane AND  Gum  Tissue,  Enlarged  from  Fig.  42,  Showing  Active  Inflamma- 
tion, with  Pus  Pocket.     Dog. 

0,  Cementiim.  E,  Epithelial  Tissue.  G,  Submucous  Membrane.  I^,  Inflamed 
Peridental  ^Membrane.  J,  Alveolar  Process.  L^,  Inflammation  Extending^  through  En- 
larged Haversian  Canals.  M\  Inflamed  Fibrous  Tissue.  R.  Pus  Pocket.  V,  Violent 
Inflammation.  AA,  Point  of  Union  of  Epithelial  Tissue  and  Peridental  Membrane. 
FF,  Food  Containing  Micro-Organisms. 


X  75.     A.  A.  obj.     Zeiss.     Micro-photograph,  reduced  one-third. 

Fig.  49. — Longitudinal  Section  of  Tooth,  Alveolar  Process,  Peridental  Mem- 
brane AND  Gum  Tissue,  Enlarged  from  Fig.  42,  Showing  Active  Inflamma- 
tion WITH  Pus  Pocket.     Dog. 

C,  Cementuni.      E,   Epithelial   Tissue.     J,   Alveolar   Process.      M^,   Inflamed   Fibrous 
Tissue.     E,  Pus  Pocket.     V,  Violent  Inflammation. 


KESEARCHES    ON    ANIMALS    IN    INTERSTITIAL    GINGIVITIS.  149 

seen  three  divisions  of  the  pnlp  (D)  extending  through  three 
separate  canals  in  the  cementum  (C).  Cementosis  (CC)  may 
be  seen  at  the  end  of  the  root.  Lacunar  absorption  is  going  on 
(0).  Thus  results  a  building  up  and  tearing  down  of  the  same 
tissue  from  the  same  cause,  interstitial  gingivitis. 

Fig.  46  shows  inflammation  of  the  peridental  membrane  {V) 
with  epithelial  debris  (W)  scattered  throughout  the  field. 

Fig.  47  is  a  section  through  the  jaw  and  incisor  tooth,  show- 
ing the  relation  of  the  structures  to  each  other  in  a  severe  case  of 
interstitial  gingivitis  and  pyorrhoea  alveolaris.  The  tooth  is  at- 
tached at  only  a  very  small  portion  of  the  apical  end  of  the  root. 
The  disease  has  been  of  long  standing.  Absorption  of  the  alveo- 
lar process  on  one  side  has  progressed  on  fully  one-half  of  the 
root,  while  upon  the  other  about  one-third  the  distance.  Inflam- 
mation commenced  at  the  gingival  border  and  extended  through 
the  periosteum  (H).  peridental  membrane  (I)  and  alveolar  proc- 
ess (J).  Marked  inflammation  (V)  has  occurred  in  the  mucous 
membrane  fold.  An  abscess  has  formed  with  a  fistula  extending 
to  the  gingival  border.  The  thin  border  at  the  left  of  the  fis- 
tulous tract  is  the  epithelium  layer  next  to  the  tooth.  It  is  evi- 
dent that  the  pus  burrowed  to  the  surface  through  the  struc- 
ture instead  of  between  the  epithelium  and  the  tooth.  A  similar 
abscess  and  fistulous  tract  are  evident  upon  the  gingival  border 
on  the  opposite  side  of  the  tooth.  The  irritation  produced  by 
the  movement  of  the  tooth  has  caused  the  cementoblasts  to  de- 
posit large  quantities  of  material  upon  the  sides  and  the  end  of 
the  root.  The  main  nerve  trunks  (U)  may  be  seen  at  and  below 
the  end  of  the  root. 

Fig.  48  illustrates  the  alveolar  border  on  the  right  side  of 
Fig.  45,  greatly  amplified.  This  shows  the  progress  of  intersti- 
tial gingivitis  extending  through  the  alveolar  process  producing 
absorption  with  intense  inflammation  of  the  peridental  mem- 
brane and  abscess  with  fistulous  tract. 

Fig.  49  shows  a  similar  process  amplified  from  the  left  side  of 
Fig.  47.  It  is  interesting  to  note  in  this  illustration  that  the 
fibers  of  the  sub-epithelium  pass  down  and  become  interwoven 
with  the  coarser  fibers  of  the  periosteum  in  just  the  opposite 
direction  from  those  in  the  other  side  of  the  tooth,  and  in  other 


150 


INTERSTITIAL    GINGIVITIS. 


illustrations.  The  fibers  from  the  inncoiis  membrane  along  the 
side  of  the  tooth  extend  down  and  into  the  peridental  membrane 
without  a  break  in  the  structure.  The  arrangement  of  the  fibers 
of  the  submucous  layer  in  producing  the  fold  is  well  illustrated 
in  the  figure.  This  picture  illustrates  inflammation  starting  in 
the  gingival  border. 

MERCURIAL  INTERSTITIAL   GINGIVITIS   IN   DOGS. 

To  secure  a  chain  of  evidence  that  interstitial  gingivitis  (due 
to  the  metals,  drugs,  uric,  lactic  and  other  acids)  commenced  in 


Proj.  1/4  inch,  ocular  lY^  inch.     Spencer. 

Fig.  50. — Longitudinal  Section  of  Gingival  Border,  Showing  Eound-Cell. 
Inflammation  Due  to  Mercurial  Poisoning. 

the  papillary  layer  of  the  sub-epithelial,  mucous  membrane,  I 
instituted  a  series  of  experiments  in  mercurialization  of  dogs. 
Dogs  for  the  purpose  were  picked  up  in  the  streets.  Some 
of  these  were  operated  upon  l)y  myself,  but  most  of  them  were 
under  treatment  at  the  Post-Graduate  Medical   School.    Care 


MERCURIAL  INTERSTITIAL    GINGIVITIS   IN    DOGS. 


151 


was  taken  to  secure  those  in  health  and  with  healthy  gums. 
Mercury  was  introduced  by  the  mouth,  skin  and  hypodermic 
injection.  It  was  no  easy  matter  to  get  them  under  influence 
of  the  drug,  since  the  power  of  the  glands  to  eliminate  the  poison 
was  enormous.  In  no  case  was  salivation  produced.  The  first 
symptom  noticed  was  exhilaration,  which  would  last  from  three 
days  to  a  w^eek.  Then  paralysis  agitans  would  continue  until 
death.  In  about  a  week  the  appetite  would  commence  to  fail 
and  it  was  difficult  to  get  the  dogs  to  take  food  of  any  kind. 
The  kidneys  and  bowels  eliminated  the  i)oison.     There  was  a 


•#  .y 


JBL. 


Pantaclir.  oil  imin.  1/12  inch  ocular.     No.  3.     Leitz. 

Fjg.  51. — Longitudinal  Section  of  Gingival  Border.  Higher  Magnification, 
Showing  Connective  Tissue  Infiltration  with  Plasma  Cells  and  Polynu- 
clear  Leucocytes.    Dog. 


rise  in  temperature.  Some  of  the  dogs  died  before  gingivitis 
was  observed.  This  demonstrated  that  not  only  does  the  nervous 
system  become  involved,  but  the  organs  of  the  body  may  be 
morbidly  affected  and  death  ensue  before  the  gums  show  symp- 
toms of  disease.    Some  dogs  were  killed  after  the  gums  became 


152 


INTERSTITIAL    GINGIVITIS. 


diseased.  The  time  required  to  obtain  results  was  from  three  to 
eight  weeks.  The  age  and  physical  condition  of  the  dog  caused 
this  variation  in  time.  After  death  the  gum  tissue  was  dissected 
from  different  parts  of  the  jaws  and  placed  in  either  fifty  per 
cent  alcohol,  Muller's  fluid,  or  two  per  cent  formaliu. 

Sections  of  tissue  from  the  gum  margin  and  sides  were  made 
on  a  number  of  places.  Some  were  imbedded  in  paraffin,  others 
in  celluloidin.     The  sections  were  stained  according  to  various 


Pautachr.  oil  imm.  1/12  inch  ocular.     No.  3.     Lcitz. 

Fig.  52. — Longitudinal  Section  of  Gingival  Border.  Higher  Magnification, 
Showing  Round-Cell  Inflammation  Extending  to  the  Inner  Coat  of  the 
Blood  Vessel  and  also  Plasma-mast  Cells. 

methods:      Delafield's    haematoxylin,    eosin    (Unna's),    alkalin 
methylblue,  carmin,  Gramm's  stain,  etc. 

Microscopic  examination  showed  that  the  epithelial  lining  of 
the  gums  did  not  present  pathologic  changes,  but  appeared  nor- 
mal in  every  respect.  Connective  tissue  below  the  gum  epithe- 
lium (the  tissue  analogous  to  the  papillary  layer  of  the  derma 
and  the  derma  proper)  presented  unmistakable  evidences  of  a 


MERCURIAL   INTERSTITIAL    GINGIVITIS    IN    DOGS. 


15: 


mild  inflammatory  process.  There  occurred  in  this  connective 
tissue  round-cell  infiltration,  generally  moderate  but  in  some 
places  quite  dense.  This  cellular  infiltration  extended  from 
below  (where  it  was  densest)  upward  into  the  papillary  layer 
(Figs.  50  and  51).  The  densest  cellular  infiltration  usually  oc- 
curred around  the  vessels  (Fig.  51). 

Under  high  magnification,  the  cellular  infiltration  was  found 
to  consist  of  polymorphonuclear  leucocytes,  plasma  cells  and 


MmdiS^: 


Projection  %  inch,  ocular  lY-y  inch.     Spencer. 

Fig.  53. — Longitudinal  Section  of  Gingival  Border,  Showing  Eound-Cell  Infil- 
tration IN  THE  Connective  Tissue  and  Extending  into  the  Papillae.    Dog. 

plasma-mast  cells,  the  latter  with  coarse  basophihc  granulations 

(Figs.  52  and  53). 

In  some  places  were  seen  between  the  round  cells,  short, 
broad  fusiform  cells,  the  protoplasm  of  which  took  quite  well 
basic  methylblue.  These  cells  resemble  very  much  fibroblasts 
and  appear  to  be  derivations  of  the  plasma  cells  (Fig.  54).  No 
bacteria  were, found  either  in  the  areas  of  cellular  infiltration 

(inflammatory  areas)  or  elsewhere.    In  these  cases  it  is  obvious 


154 


INTERSTITIAL    GINGIVITIS. 


Pantachr.  oil  inim.  ]/12  inch  ocular.      \o.  .!.      Lcitz. 
Fig.  54. — Longitudinal  Section  of  Gingival  Border,  Showing  Round-Cell  Inflam- 
mation Due  to  Mercurial  Poisoning.     Higher  Magnification. 


Fig.  55. 
A   monkey  skull   showing  absorption   of  the   alieolar  process    (original).     The   right 
central  and  left  lateral  have  dropped  out.     The  alveolar  process  is  absorbed  so 
that  all  teeth  are  loose. 


MERCURIAL    INTERSTITIAL    (ilXCilVITIS    IN    DOCS.  155 

that  there  had  occurred  a  mild  inflainination  of  the  gums  (gingi- 
vitis). While  this  could  not  be  seen  with  the  naked  eye,  micro- 
scopic examination  demonstrated  histologic  features  of  an  in- 
flammatory process.  The  absence  of  bacteria  justified  the 
belief  that  this  inflammation  was  not  of  microbic  origin,  but  due 
to  mercury,  which  by  its  well-kiiown  chemotactic  influence  pro- 
duced the  histologic  changes  of  an  inflammation. 

Fig.  55  is  the  skull  of  a  monkey  who  died  aged  one  year  of 
tuberculosis.  Absorption  of  the  alveolar  process  is  the  result 
of  autointoxication  acting  upon  a  depleted  organism.  The  right 
superior  and  inferior  central  and  lateral  incisors  have  loosened 
and  dropped  out.  The  roots  of  all  the  teeth  are  exposed  to  a 
marked  extent.    The  teeth  could  be  removed  with  the  fino-ers. 


CHAPTER  XV. 

KESEARCHES    ON    HUMAN    IN    INTERSTITIAL    GINGIVITIS. 

While  hundreds  of  slides  conld  be  adduced  in  support  of  this 
chain  of  evidence,  sufficient  have  been  given  to  permit  of  the 
introduction  of  evidence  from  other  phases  of  the  subject. 

The  following  autopsy  was  made  by  L.  Hektoen  on  an  old 
man,  in  whose  case  the  pathologic  diagnosis  was  as  follows: 
Senile  marasmus  (senile  emphysema,  senile  sclerosis  of  the 
aorta,  atrophy  of  the  parenchymatous  organs),  scurvy  (haBmor- 
rhagic  gingivitis);  chronic  aortic  and  mitral  endocarditis; 
fibrous  myocarditis;  chronic  nephritis;  caseo-calcareous  areas 
in  the  right  apex,  spleen  and  left  adrenal ;  double  hydrothorax ; 
bronchitis ;  fibroma  of  the  stomach ;  amputation  of  the  left  lower 
extremity  at  the  lower  third  of  the  thigh.  The  findings  unre- 
lated to  the  scope  of  the  present  investigation  are  omitted.  The 
gums  were  found  swollen,  and  here  and  there  infiltrated  with 
blood.  There  was  purulent  matter  about  the  roots  of  the  teeth, 
many  of  which  were  loosened  and  some  of  which  could  be 
removed  with  the  fingers.  The  roots  of  the  loosened  teeth  were 
covered  with  a  granular  grayish  material. 

Bacteriologic  examination  of  the  root  of  the  tooth  gave  the 
following  results :  Tube  of  bouillon  from  which  agar  plates 
were  made,  inoculated  twenty-four  hours  before  date,  July  29, 
1898.  There  were  two  varieties  of  colonies:  Both  grayish 
white.  One  kind  is  round,  pin-head  size,  slightly  elevated,  with 
thin,  wavy,  but  sharply  defined  border.  Finely  granular.  Media 
inoculated  from  one  of  these.  Agar  Slant:  White,  tallow- 
like growth  along  the  track  of  the  needle,  with  thin,  more  trans- 
lucent layer  covering  the  rest  of  the  surface.  Only  moderately 
elevated.  Greenish  tinge  given  to  media.  Potato:  Elevated, 
*' clumpy"  growth,  white  on  top,  confined  to  needle  track. 
Potato  much  darkened.  Blood  Serum:  Gray,  waxy  growth, 
little  elevated,  sharply  defined  and  thick  border.  Gelatin  Slab: 
Saucer-shaped  liquefaction  at  upper  part,  more  tubular  in  deeper 


RESEARCHES  ON  HUMAN  IN  INTERSTITIAL  GINGIVITIS.  157 

portions.  Flocculent  masses  tliroiighoiit.  Glucose  Agar:  Gas 
produced,  white,  thick  growth  on  top.  Milk:  Alkaline,  soft 
coagulation.  Bouillon:  Cloudy.  Characteristics:  Rapid  growth, 
a  sour,  nauseating  odor  given  off  from  all  media.  Morphology: 
Large  coccus,  single,  in  pairs  and  in  groups.  Stains  easily  by 
ordinary  methods,  also  by  Grams.  The  smaller  colonies  on  agar 
plates  (pin-point  sized  in  center)  with  nearly  transparent,  illy 
defined  pai'ipheral  zone.  Border  indistinct.  Central  portion  in 
gray.  Finely  granular  throughout.  Agar  Slant:  Gray  film 
over  entire  surface,  somewhat  thicker  along  the  inoculation 
streak.  At  bottom  there  is  a  nearly  white  growth.  Very  light, 
greenish  tinge  to  media.  Blood  Serum:  Like  on  agar.  Potato: 
Heavy  dirty  gray  growth,  wavy  and  sharply  defined  border. 
Looks  like  bunch  of  cauhflower.  Gelatin  Slab:  Liquefied, 
saucer-shaped  at  top,  tubular  in  deeper  part.  Growth  mostly 
in  upper  stratum.  Lit.  Milk:  Negative.  Bouillon:  Cloudy. 
Glucose  Agar:  Gas  produced.  Characteristics:  Eapid 
growth,  stinking  odor  from  all  media.  Morphology:  Small, 
slender  baciUi;  actively  mobile,  spores.  Takes  ordinary  stains 
readily  and  is  not  decolorized  by  Gram's  method. 

Only  the  lower  frontal  teeth  and  corresponding  part  of  the 
jaw  could  be  examined.  The  epithelial  covering  of  the  gums 
appeared  to  be  quite  intact.  Li  some  places  it  was  a  little  thick- 
ened, and  its  lower  layers  infiltrated  with  new  cells.  The  sub- 
epithelial tissue  was  much  thickened,  presenting  the  general 
structure  of  an  inflammatory  granulation  tissue  of  some  stand- 
ing. Areas  occurred  in  which  there  were  many  new  cells  and 
but  little  stroma.  In  other  foci  the  tissue  was  more  fibrous,  the 
new  cells  running  in  bands.  Here  and  there  occurred  free  and 
intracellular  granular,  yellow  pigment.  Typical  hyaline  bodies 
of  various  sizes,  and  staining  a  precise  bluish  violet  with  Gram's 
method,  were  found  in  rather  small  numbers.  In  some  places 
small  sub-epithelial  abscesses  were  met  with,  which  (in  the 
instance  of  a  district  including  a  lower  incisor)  were  really  sub- 
periosteal. TlLe  contents  consisted  of  nuclear  detritus  and  bac- 
teria (mostly  cocci)  which  have  accumulated,  especially  upon 
and  in  the  walls  of  the  minute  cavities  extending  from  such  an 
abscess.    There  seems  to  be  a  complete  occlusion  of  the  vessels 


X  40.     35  M.  M.     Zeiss.     Micro-photograpli,  reduced  one-third. 

Fig.  56. — Longitudinal  Section  of  Tooth,  Alvj;olar  Process  and  Gingival  Border, 

Showing  Active  Inflammation  in  Scurvy  in  Man. 

B,  Dentine.  C,  Cementum.  B,  Epithelial  Tissue.  G,  Submucous  Membrane. 
H,  Periosteum.  J,  Alveolar  Process.  L,  Haversian  Canals.  M,  Fibrous  Tissue.  Y, 
Violent  Inflammation.  AA,  Point  of  Union  of  Epithelial  Tissue  and  Peridental  Mem- 
brane.    RR,  Space  Pocket  from  Want  of  Union  of  the  Epithelial  Fold. 


X  40.     35  M.  M.     Zeiss.     Micro-photograph,  reduced  one-third. 

Fig.  57. — Longitudinal  Section  of  a  Tooth,  Alveolar  Process  and  Gingival 
Border,  Showing  Active  Inflammation  in  Scurvy  in  Man. 

B,  Dentine.  C,  Cementum.  E,  Epithelial  Tissue.  G,  Submucous  Membrane. 
V,  Violent  Inflammation.  Z,  Sloughing  of  the  Epithelial  Tissue  Due  to  Calcic  Deposits. 
AA,  Point  of  Union  of  Epithelial  Tissue  and  Peridental  Membrane. 


X  75.     A.  A.  obj.     Zeiss.     Micro-photograph,  reduced  one-third. 

Fig.  58. — Longitudinal  Section  of  Tooth,  Alveolar  Process  and  Peridental  Mem- 
brane, Showing  Blood  Pigment  in  Blood  Vessels  of  Peridental  Membrane 
IN  Scurvy  in  Man. 

C,  Cementum.     J,  Alevolar  Process.     K,  Capillaries.     IS  Inflamed  Peridental  Mem- 
brane.    KS  Blood  Pigment  in  Capillaries. 


X  75.     A.  A.  obj.     Zeiss.     Micro-photograph,  reduced  one-third. 

Fig.  59. — Longitudinal  Section  of  Tooth  and  Gingival  Border,  Showing  Active 
Inflammation  Extending  through  the  Mucous  and  Peridental  Membranes. 
Scurvy  in  Man. 

B.  Dentine.  C,  Cementiim.  E,  Epithelial  Tissue.  V,  Violent  Inflammation.  AA, 
Point  of  Union  of  Epithelial  Tissue  and  Peridental  Membrane.  RR,  Space  Pocket 
from  Want  of  Union  of  Epithelial  Fold.     M\  Inflamed  Fibrous  Tissue. 


162  INTERSTITIAL    GINGIVITIS. 

(capillaries)  with  typical  bacteria  masses,  staining  a  peculiar 
bluish  violet  color  with  hematoxylin,  and  blue  with  Gram's 
method,  so  that  the  vessels  presented  the  appearance  of  being 
very  successfully  filled  by  an  infection  mass :  the  small  dilata- 
tions, the  branches  and  the  larger  vessels  (judging  from  struc- 
ture these  seemed  to  be  veins)  were  sometimes  brought  out  very 
nicely.  The  intravascular  growth  of  bacteria  extended  into  the 
bone  below  as  well  as,  and  more  especially  into,  the  peridental 
membrane.^  These  abscesses  (suppurative  periostitis)  occur 
almost  exclusively  upon  the  inner  surface  of  the  alveolar  proc- 
ess, being  confined  (as  far  as  there  was  occasion  to  observe)  to 
the  external  aspect  of  the  process.  There  was  always  a  thin, 
sound  layer  of  bone  separating  the  abscess  from  the  peridental 
membrane.  Very  generally  the  spaces  in  the  adjacent  bone 
were  filled  with  a  cellular  fibrous  tissue  in  which  occurred  islands 
of  osteoid  tissue.  The  bone  trabeculne  were  generally  covered 
by  a  thin  layer  of  osteoid  tissue,  which  (from  the  greater  num- 
ber of  cells  it  contains,  as  compared  with  the  other  bones)  must 
be  newly  formed.  Rows  of  osteoblasts  were  found  often  upon 
the  trabeculae.  Few  Howship's  lacunaB  were  found,  and  these 
were  filled  with  small  cells.  There  were  no  osteoclasts  in  the 
areas  about  the  abscesses.  The  bone  outside  of  the  alveolar 
process  was  quite  unchanged. 

The  ''bacterial  thrombosis"  not  unusually  extended  into  the 
peridental  membrane,  which  then  refused  to  stain  as  clearly  as 
normal.  The  upper  part  of  the  peridental  membrane  was 
usually  the  seat  of  cell  proliferation,  and  of  the  formation  of 
fibrous  tissue,  due  to  the  direct  extension  of  the  similar  process 
in  the  sub-epithelial  connective  tissue  of  the  gingivus.  There 
were  no  indications  that  the  process  began  below,  at  the  apex  of 
the  tooth,  for  example,  and  extended  upward.  In  the  peridental 
membrane,  and  often  connected  with  the  cementum  of  every 
tooth  examined,  were  very  many  so-called  calcospherites ;  cal- 
cified, concentrically  lamellated,  round  or  oval  bodies,  not  unlike 
the  ''corpora  amylacea. "    In  many  instances,  it  seemed  as  if  the 


^  The  abscesses  have  a  definite  outline  or  wall  of  ordinary  cellular  fibrous  tissue 
displaying  striking  evidences  of  active  inflammation.  The  tissue  about  the  capilla- 
ries filled  with  bacteria  refuse  to  stain  clearly,  but  there  are  no  signs  of  inflammation. 


EESEAKCliE8  ON  HUMAN  IN  INTEKtiTITIAL  GINGIVITIS.  163 

body  liad  formed  in  the  cement  or  at  its  margin — the  cement 
presenting  here  a  nodular  condition. 

Fig.  56  ilhistrates  a  section  through  the  tissues  of  the  jaw 
and  cuspid  tooth.  The  epitheUum  is  not  so  dense  and  thick  as 
in  a  similar  section  from  the  dog.  Inflammation  extends  along 
the  papillary  layer  of  the  submucous  membrane  (G)  and  involves 
the  deeper  structures.  The  mucous  membrane  layer  has  doubled 
upon  itself,  forming  a  pocket  (RR).  Violent  inflammation  is 
evident  at  V.  This  is  of  unusual  interest,  since  it  demonstrates 
that  inflammatory  products  may  be  carried  by  the  blood  vessels 
anywhere  throughout  the  alveolar  process,  and  may  result  in 
abscesses.  The  inflammation  extends  throughout  the  periosteum 
(H),  the  fibers  of  which  extend  from  the  root  of  the  tooth  over 
the  border  of  the  alveolar  process  (J).  There  the  coarse  fibers 
of  the  periosteum  contrast  decidedh^  with  the  finer  fibers  of  the 
sub-epithelium.  Absorption  and  contraction  of  the  alveolar 
process  (fully  one-half  the  length  of  the  root  of  the  tooth)  has 
taken  place,  as  well  as  lateral  absorption.  The  inflammatory 
process  extends  through  the  Haversian  canals  (L). 

Fig.  57  is  a  section  through  the  jaw  at  the  lateral  incisor. 
The  epithelium  (E)  is  seen  upon  the  outer  surface  of  the  alveolar 
process  as  far  as  the  root  of  the  tooth.  The  inner  fold  next  to 
the  tooth  has  disappeared  through  encroachment  of  deposits 
which  have  been  destroyed  by  nitric  acid.  Inflammation  ex- 
tends throughout  tlie  entire  submucous  membrance  (G).  The 
most  marked  inflammation  in  this  case  is  entirely  upon  the 
outer  border   (V). 

Fig.  58  shows  a  section  of  the  peridental  membrane  (I) 
and  alveolar  process  (J).  Capillaries  (K)  interlace  through 
the  field,  the  largest  number  being  distributed  along  the 
alveolar  wall.  Blood  pigment  containing  bacteria  is  notice- 
able (K'). 

Fig.  59  is  an  amplification  of  a  section  depicted  in  Fig.  56. 
This  gives  a  clearer  idea  of  the  folding  of  the  epithelium  (E) 
and  submucous  membrane  (G)  layer  upon  itself,  forming  a 
pocket  (RR),  in  which  may  be  seen  an  accumulation  of  food  and 
bacteria.  It  also  shows  extensive  inflammation  throughout  the 
entire  field.     Marked  inflammation  is  evident  at  V.     The  point 


X  75.     A.  A.  obj.     Zeiss.     Micro-photograph,  reduced  one-third. 

Fig.  60. — Cross  Section  Peridental  Membrane,  Showing  Active  Eound-Cell  In- 
flammation.   Scurvy  in  Man. 

C,  Cementum.     V,  Violent  Inflammation..     W,   Epithelial  Debris.     EO,   Endar- 
teritis Obliterans. 


X  75.     A.  A.  obj.     Zeiss.     Micro-photogvaph,  reduced  one-third. 

Fig.  61. — Cross  Section  of  Inflamed  Peridental  Membrane.    Scurvy  in  Man. 

I,  Peridental  Membrane.  J,  Alveolar  Process.  K,  Capillaries.  L,  Haversian 
Canals.  BB,  Blood  Vessels  of  Von  Ebner  Preceding  Perforating  Canals.  EO,  Endar- 
teritis Obliterans.    W,. Epithelial  Debris. 


X  75.     A.  A.  obj.     Zeiss.     Micro-photograph,  reduced  one-third. 

Tig.  62.— Cross  Section  of  Tooth,  Alevolar  Process  and  Peridental  Membrane, 
'  Showing  Active  Inflammation  and  Absorption  of  Bone.    Scurvy  in  Man. 

C,  Cementum.     I,  Peridental  Membrane.     J,  Alveolar  Process.     P,  Perforating  Canal 
Absorption.     V,  Violent  Inflammation, 


X  40.     35  M.  M.  obj.     Zeiss.     Micro-photograph,  reduced  one-third. 

Fjg.  63. — Cross  SectioIn  of  Peridental  Membrane  and  Alveolar  Process,  Showing 
Active  Inflammation  and  Abcess.    Scurvy  in  Man. 

J,  Alveolar  Process.     %  Bacteria.     Y,  Abcess.     T,  Inflamed  Peridental  Membrane. 
L,  Inflammation  Extending  through  Enlarged  Haversian  Canals. 


■  X  75.     A.  A.  obj.     Zeiss.     Micro-photograph,  reduced  oue-third. 

-piQ   64 Cross  Section  of  Peridental  Membrane  and  Alveolar  Process,  Show- 

"  iNG  Active  Inflammation  and  Another  Larger  Abcess.    Scurvy  in  Man. 

J,  Alveolar  Process.  P,  Perforating  Canal  Absorption.  V,  Violent  Inflammation. 
Y,  Abcess.  1\  Inflamed  Peridental  Membrane.  U,  Inflammation  Extending  through 
Enlarged  Haversian  Canals. 


EESEAECHES  ON  HUMAN  IN  INTEESTITIAL  GINGIVITIS. 


169 


of  union  of  the  siib-epithelial  layer  and  the  periosteum  is  shown 
(AA). 

Fig.  60  illustrates  inflammation  of  the  peridental  membrane 
with  epithelial  debris  (W)  scattered  over  the  field.  Endarteritis 
obliterans  (EO)  is  also  noticed  at  various  positions.  Marked 
inflammation  may  be  seen  at  V. 

Fig.  61  illustrates  a  section  of  the  peridental  membrane  (I) 
and  alveolar  process  (J)  with  inflammation  extending  through- 
out.    Capillaries   (K)   are  also  noticeable  in  large  quantities, 


X  300.     No.  2  projection  ocular.     D.  D.  obj.     Zeiss. 

Fig.  65. — Cross  Section  of  Tooth,  Alveolar  Process  and  Peridental  Membrane, 
Showing  Active  Inflammation  with  Calcospherite  in  Membrane.  Scurvy 
IN  Man. 

B,  Dentine.  C,  Cementum.  I,  Peridental  Membrane.  J,  Alveolar  Process. 
HH,  Calcospherite.  J*,  Inflamed  Peridental  Membrane.  L^,  Inflammation  Extending 
through  Enlarged  Haversian  Canals. 


nearer  the  alveolar  process  than  the  root  of  the  tooth.  Epithe- 
lial debris  is  evident  at  W.  Endarteritis  obliterans  (EO)  may 
be  seen  in  different  portions  of  the  field.  Inflammation  has 
extended  into  the  Haversian  canals  (L)  but  absorption  has  not 


170  INTERSTITIAL    GINGIVITIS. 

occurred  to  any  great  extent.  The  blood  vessels  of  Von  Ebner 
(BB)  are  quite  well  shown. 

Fig.  62  is  a  section  showing  the  cementum  (C),  the  i)eri- 
dental  membrane  (I)  and  the  alveolar  process  (J).  Marked 
inflammation  extends  through  the  peridental  membrane,  thence 
through  the  Haversian  canals  (which  are  entirely  obliterated). 
Absorption  of  the  trabeculae  (halisteresis)  has  resulted  to  the 
extent  that  what  remains  of  the  alveolar  process  (J)  are  islands 
of  bone  held  in  place  by  the  fibrous  tissue.  Blood  vessels  of 
Von  Ebner  with  perforating  canals  are  seen  at  P. 

Fig.  63  shows  a  section  of  the  peridental  membrane  and 
alveolar  process  wdth  a  large  abscess  originally  within  the 
alveolar  wall.  Inflammation  spreading  through  the  peridental 
membrane  has  occurred  at  Y,  while  the  decalcified  alveolar 
process  is  also  shown  (J).  Violent  inflammation  has  taken 
place  within  the  alveolar  wall,  and  an  abscess  (Y)  has  formed. 
The  wall  of  the  abscess  is  distinctly  seen,  with  masses  of  bac- 
teria (T)  clinging  to  the  inner  sides.  The  process  of  halisteresis 
(Q)  (bone  decalcification)  is  seen  as  a  result  of  the  violent 
inflammation.  The  entire  wall  next  to  the  peridental  membrane 
and  about  the  abscess  has  been  destroyed,  and  the  different 
stages  in  the  process  by  which  this  has  been  accomplished  are 
beautifully  shown. 

Fig.  64  illustrates  a  larger  abscess  (Y)  from  another  loca- 
tion. This  is  also  situated  mthin  the  alveolar  wall,  showing 
that  the  inflammatory  products  extend  through  the  blood  ves- 
sels. Marked  inflammation  is  seen  upon  the  side  next  to  the 
peridental  membrane  (T),  while  rapid  absorption — halisteresis 
(Q)  and  perforating  canal  (P) — is  proceeding  at  the  borders 
of  the  abscess  and  nearest  the  alveolar  process. 

Fig.  65  shows  a  section  of  a  tooth  (B  and  C),  inflamed 
peridental  membrane  (I'),  with  absorption  of  the  alveolar  proc- 
cess  (J).  In  the  inflamed  peridental  membrane  may  be  seen 
a  calcospherite,  oblong  in  form. 

INTERSTITIAL  GINGIVITIS  IN   MAN   FROM  DRUG  ACTION. 

A  forty-eight-year-old  merchant  was  dyspeptic,  debilitated 
and  asthmatic,  and  for  the  treatment  of  these  conditions  he  had 
been  under  calomel  and  tonics  for  a  little  less  than  two  weeks. 


RESEARCHES  OX  HU:MAN  IX  IXTERSTITIAL  GlX(iIVITIS.  171 

When  lie  came  under  observation,  the  mucous  membrane  and 
gums  were  then  nuich  inflamed.  There  was  marked  sialorrhoea. 
The  teeth  were  loose.  The  gums  were  swollen.  Pus  oozed  from 
the  gums.  The  breath  had  a  decided  metallic  odor.  At  my  sug- 
gestion, his  medical  attendant  stopped  the  calomel.  He  was 
then  ordered  six  pints  of  spring  water  daily.  The  gums  were, 
on  alternate  days,  saturated  with  iodin.  In  a  few  days  the  sore- 
ness and  swelling  were  so  reduced  that  the  de])osits  could  be 
removed.  The  patient  was  discharged  cured  in  a  short  time 
other  than  as  to  tlio  riglit  inferior  second  molar,  which  was  so 
loose  as  to  require  removal.    This  tootli  was  placed  immediately 


Fig.  66. — Shows  a  Small  Fragment  of  Inflamed  Peridental  Membrane. 

in  fifty  per  cent  alcohol  for  twenty-four  hours  and  then  removed 
to  absolute  alcohol  for  twenty-four  hours  more.  The  membranes 
had  receded  about  two-thirds  the  length  of  the  root.  Sections 
for  microscopic  purposes  were  made  from  the  lower  third  of  the 
root.  Of  these  sections,  Fig.  66  shows  a  small  fragment  of  in- 
flamed peridental  meml)rane.  Fig.  67  exhibits  violent  round-cell 
inflammation,  degeneration  and  liquefaction  of  tissue. 

A  thirty-five-year-old  diabetic  painter  came  under  observa- 
tion for  plumbic  poisoning.  His  gums  were  swollen.  There  was 
decided  sialorrhcea.  The  teeth  were  loose.  Pus  flowed  from  the 
gums.     He  was  placed  on  ozonate  spring  water  and  the  gums 


172 


INTERSTITIAL    GINGIVITIS. 


were  saturated  with  iodin  on  alternate  days.  Three  loose  teeth 
were  removed  and  placed  in  alcohol.  Sections  from  the  upper 
third  of  the  left  superior  second  bicusi^id  gave  results  on  micro- 
scopic examination  similar  to  those  already  described  as  occur- 
ring in  mercurial  poisoning.  Fig.  68  shows  round  cells  of  in- 
flammation. Fig.  69  illustrates  very  marked  degeneration  of 
the  peridental  membrane.  In  the  lower  right-hand  corner  are 
seen  the  root  of  the  tooth,  dentine  and  cementum.  The  whole 
surface  of  the  peridental  membrane  is  in  an  advanced  phase  of 


Fig.  67. — Violent  Eouxd  Cell  Inflammation,  Degeneration  and 
liquification  of  tissue. 


inflammation.  Just  at  the  border  of  the  root  is  evident  an  area 
of  membrane  softening.  Just  beyond,  but  joining,  is  noticeable 
breaking  down  of  tissue.  In  the  center  are  seen  two  areas  of 
softened  tissue  more  advanced  in  degeneration. 

One  occupation  disease  which  has  been  ignored  in  the  etiology 
of  interstitial  gingivitis  is  ''brass-workers'  ague. "  In  almost  all 
brass-workers,  a  stain  varying  from  a  bright  to  a  brownish  green 
IB  detectable  on  the  necks  of  the  teeth  between  the  crowns  and 


EESEAECHES  ON  HUMAN  IX  INTERSTITIAL  GINGIVITIS.  173 

the  gum  insertion.  This  is  most  obvious  in  the  upper  jaw. 
After  a  while,  as  E.  Hogben  -  has  shown,  the  teeth  become 
loosened  and  fall  out.  Before  these  changes  in  the  gum  occur 
nervous  symptoms  have  developed  from  the  brass  poisoning. 

Arsenic  should  be  taken  into  account  in  the  etiology  of  inter- 
stitial gingi\itis.  This  drug  has  a  very  decided  tendency  in  cer- 
tain subjects  to  cause,  even  in  small  doses,  marked  stomatitis 
and  irritation  of  the  mucous  membranes  throughout  the  body. 

Tartar  emetic  and  the  other  preparations  of  antimony,  pro- 
ducing irritation  of  tlie  mucous  membranes  of  the  mouth  and 
elsewhere,  may  act  as  predisposing  and  exciting  factors  of  inter- 
stitial gingivitis." 


Fig.  68. — Section  of  Pericemextai,  Membrane  Showing  Eound  Cell  Inflammation. 

Among  the  drugs  which  should  be  taken  into  account  in  the 
etiology  of  interstitial  gingivitis  is  potassium  bromide.  This 
produces  in  certain  individuals,  or  when  given  to  excess,  marked 
increase  of  the  saliva  with  irritation  of  the  mucous  membranes 
of  the  mouth,  followed  later  by  dryness  of  the  mouth  and  shrink- 
ing of  the  gums.  The  bromides  have,  as  H.  C.  B.  Alexander  * 
has  shown,  a  teudency  to  irritate  all  the  mucous  membranes  of 
the  body  as  well  as  the  skin.     Therefore,  in  dealing  with  cases 


'  Birmingham  Medical  Eeview,  1887. 
^Lewin:    Untoward  EiFects  of  Drugs. 
*  Alienist  and  Neurologist,  July,  1896. 


174 


INTERSTITIAL    GINGIVITIS. 


of  interstitial  gingivitis  in  wliicli  tlic  l)roini<les  are  being  taken, 
this  factor  should  not  be  neglected.  In  these  cases  the  symptoms 
dne  to  the  bromides  are  ax)t  to  be  charged  to  the  nervous  state  for 
which  the  bromides  have  been  given.     The  irritation  of  the 

mncons  membrane  by  the  bromides  may  occur  quite  early  among 


Fig.  69. — Marked  Inflammation  and  Degeneration  of  the  Peridental  Membrane 
Showing  Four  Peridental  Abscesses. 


the  untoward  effects  produced  by  them.  In  all  probability  the 
bromide  rather  than  the  alkali  is  the  source  of  these  untoward 
effects. 

What  is  true  of  the  bromides  is  also  true  to  an  even  greater 
degree,  as  has  elsewhere  been  shown,  of  the  iodides. 


CHAPTER  XVI. 

RESEARCHES  ON  HUMAN   IN  PERICEMENTITIS. 

Referring-  to  Chapter  VI  we  find  that  the  peridental  mem- 
brane is  a  tibrons  tissue  situated  between  the  root  of  the  tooth 
on  the  one  hand  and  the  alveoUir  process  on  the  other.  It  covers 
the  root  of  the  tooth.  This  structure,  to  all  intents  and  pur- 
poses, is  a  c«)ntinuation  of  the  trabeculne  or  fibrous  tissue  in  the 
alveolar  process.  In  other  words,  the  alveolar  process  is  noth- 
ing more  or  less  than  fibrous  tissue  filled  in  with  lime  salts. 

If  a  piece  of  jaw  containing  teeth  be  placed  in  a  weak  acid 
solution  and  the  lime  salts  dissolved,  there  would  be  no  distinc- 
tion, under  the  microscope,  in  the  remaining-  structure  from  the 
root  of  the  tooth  to  the  outer  surface  including  the  periosteum 
except  in  quality  of  fibers.  When  a  low  form  of  inflammation  is 
set  up  in  the  alveolar  process,  the  lime  salts  are  absorbed,  leav- 
ing the  fibrous  tissue  in  like  manner.  If  on  the  other  hand,  the 
inflammation  is  more  intense,  the  trabeculcT  or  fibrous  tissue  is 
also  destroyed. 

Irritations  of  a  local  nature  first  produce  a  gingivitis  of  the 
gum  tissue  which  extends  along  the  blood  vessels  into  the  deeper 
tissues  and  assumes  an  interstitial  character.  When  the  irrita- 
tions are  constitutional,  due  to  autointoxication,  drug,  or  other 
irritation  and  poisons,  the  deeper  tissues  become  involved,  then 
assuming  an  interstitial  character,  later  affect  the  gums,  pro- 
ducing gingivitis.  When  the  peridental  membrane  becomes  in- 
volved, whether  from  local  or  constitutional  causes,  it  is  termed 
pericementitis.  This  disease  is  always  recognized  by  soreness 
and  a  slight  elongation  of  the  tooth  or  teeth. 

If  the  cause  be  slight  or  if  removed,  the  membrane  will  re- 
turn to  its  normal  condition.  On  the  other  hand,  if  the  cause  be 
severe  and  of  long  standing-  the  inflammation  will  become 
chronic,  resulting  in  absorption  of  the  alveolar  process  and  per- 
haps abscess. 


176  INTERSTITIAL    GINGIVITIS. 

A  low  form  of  pericementitis  may  act  upon  the  surrounding 
tissues  in  different  ways,  depending,  to  a  great  extent,  upon  the 
nervous  system.  First,  if  there  are  no  corresponding  teeth  for 
antagonism  on  the  opposite  jaw,  the  inflammation  will  cause  a 
deposition  of  lime  salts  in  the  alveolar  process,  causing  elonga- 
tion which  continues  until  the  tooth  or  teeth  meet  resistance. 
Second,  exostosis  of  the  cementum  of  the  tooth.  Third,  the 
inflammation  results  in  peridental  or  alveolar  abscess.  Later, 
especially  if  the  irritation  be  of  a  constitutional  nature,  the 
inflammation  will  cause  absorption  of  the  alveolar  process  and 
exfoliation  of  the  teeth. 

A  seamstress  bites  her  thread,  pericementitis  results.  If 
treatment  be  resorted  to  and  the  habit  stopped,  the  peridental 
membrane  will  be  restored  to  health.  If,  however,  this  habit 
be  continued,  interstitial  gingivitis  results,  with  absorption  of 
the  bone  and  loosening  of  the  teeth.  The  habit  of  biting  threads 
with  the  teeth  causes  an  extra  amount  of  work  upon  the  peri- 
dental membrane.  Persons  suffering  with  autointoxication 
would  naturally  find  such  teeth  first  involved  in  interstitial 
gingivitis.  The  same  results  follow  when  a  low  form  of  inflam- 
mation occurs  in  the  three  classifications  just  mentioned  above. 
Persons  of  low  vitality,  poorly  nourished  people  suffering  with 
prolonged  sickness  and  pregnant  women  have  periostitis  and 
general  interstitial  gingivitis.  Persons  overworked  or  suffering 
with  neurasthenia  are  prone  to  it. 

In  syphilis,  pericementitis  and  interstitial  gingivitis  are  set 
up  and  not  only  in  the  alveolar  proces;.;,  but  all  bones  of  the  body 
may  become  involved,  causing  hypertrophy  as  well  as  absorp- 
tion and  death  of  bone.  Heat  and  allied  irritation  will  produce 
interstitial  gingivitis  and  bone  absorption. 

Some  more  severe  forms  of  pericementitis  and  interstitial 
gingivitis  deserve  attention  from  the  irritation  point  of  view. 
I  have  for  years  moved  the  teeth  of  dogs  with  regulating  appli- 
ances, using  a  screw  with  sixty  threads  to  the  inch.  In  some 
the  screw  was  turned  one-fourth  round,  in  otliers  one-half,  and 
in  still  others  one  full  turn  once  a  day.  Some  of  the  dogs  were 
killed  in  three  days,  others  in  a  week,  and  still  others  in  two 
weeks.    By  this  method  the  simplest  and  most  severe  forms  of 


EESEARCHES  ON   HUMAN  IN  PERICEMENTITIS. 


177 


pressure  were  applied,  the  length  of  time  being  brief  as  well  as 
extended.  These  tissues  were  decalcified,  cut,  stained  and 
mounted  for  the  microscope.  In  every  case  inflannnation  of  the 
pericementum  was  produced.  This  disproves  the  theory  so  long 
held,  that  bone  absorption  in  regulating  teeth  is  purely  a  physio- 
logic process.  Teeth  were  also  extracted  from  dogs  and  after 
a  week  they  were  killed.  The  bone  was  decalcified,  cut,  stained 
and  mounted  for  the  microscope.  The  absorption  was  inflamma- 
tory in  character.  The  jaws  of  dogs  and  monkeys  who  were 
erupting  the  permanent  teeth  were  treated  in  like  manner.    Ab- 


FlGURE   70. 

Inflauimation  of  the  gum  margin  (original). 


sorption  of  the  alveolar  process  to  allow  the  teeth  to  pass  into 
position  was  of  inflammatory  type.  Simple  irritation,  as  well  as 
severe  pressure,  hence  produces  the  same  pathologic  process, 
pericemental  inflannnation  and  interstitial  gingivitis. 

The  blood  vessels  which  supply  the  gums,  pericemental  mem- 
brane and  alverilar  process  are,  as  I  have  elsewhere  demon- 
strated closely  connected.  Those  in  the  pericemental  membrane 
form  a  plexus  along  the  wall  of  the  alveolar  process,  while  only 
a  small  number  are  near  the  roots  of  the  teeth.    So  closely  con- 


178 


INTERSTITIAL    GINGIVITIS. 


nected  are  these  that  the  vessels  in  one  cannot  become  involved 
without  affecting-  those  of  the  otlier  tissues.  Hence,  gingivitis 
and  pericementitis  occur  wliich  in  reality  become  interstitial, 
or  interstitial  inflammation  appears,  which  in  reality  becomes 
gingivitis.  No  matter  wliat  the  cause  may  ])e,  or  whether  the 
initial  lesion  be  in  the  gum  or  interstitial  structure,  absorption 
of  the  alveolar  process  eventually  results. 

I  began  my  experiments  upon  the  peridental  membrane  in 
1896.  In  1897,  I  read  an  article  before  the  Section  on  Stoma- 
tology of  the  American  Medical  Association,  demonstrating  the 


Figure  71. 

Section   deeper  at   the  alveolar  honlev    (original).      Active   inflammation   around   two 
arteries  which  are  becoming  thickened. 


pathology  of  the  peritlental  membrane  from  simple  inflammation 
to  the  breaking  down  of  tissue  and  the  formation  of  abscess. 

A  bicuspid  tooth  with  a  gold  crown  attached  was  taken  from 
the  mouth  of  a  fifty-four-year-old  man.  He  was  suffering  from 
autointoxication  and  neurasthenia.  The  tooth  had  become  quite 
loose  although  the  gum  tissue  was  still  intact.  The  irritation 
was  both  local  and  constitutional  in  character,  since  the  gold 


EESEAECHES  ON   HUMAN   IN   PERICEMENTITIS. 


179 


crown  irritated  tlie  gum  margin  and  a  slight  attack  of  Bright 's 
disease  caused  self  poisoning. 

The  following  illustrations  are  taken  from  microscopic  slides 
and  magnified  four  hundred  and  eighty  diameters.  Fig.  70 
shows  the  gum  tissue.  The  epithelial  layer  shows  the  dipping 
down  of  the  legs  into  the  true  mucous  menil)rane  below  the  base- 
ment membrane,  with  round  cell  infiltration  due  to  irritation. 
Fig.  71  is  a  cross-section  of  peridental  membrane  of  the  left 
inferior  ceutral  incisor  of  a  ladv  twentv-nine  vears  of  age  who 


inflammat: 


had  been  under  my  care  for  fourteen  years.  She  was  in  the 
habit  of  biting  her  thread  with  this  tooth.  Her  occupation,  that 
of  dressmaking,  gave  her  little  or  no  exercise  and  she  was  also 
overworked.  She  drank  no  water;  she  was  suffering  from  sleep- 
lessness and  nervousness  due  to  indigestion  and  autointoxica- 
tion. Sections  of  tooth,  after  decalcification,  were  made  in  the 
usual  manner  for  the  microscope.  A  cross-section  shows  two 
blood  vessels  which  are  consideraljly  thickened  (endarteritis 
obliterans)  in  its  early  stages  with  round  cell  infiltration  in  the 
tissues  about  them. 


180 


liS'TEKSTITlAL    GINGIVITIS. 


h 


TlGURE  7lj. 
Violent  inlhiinniation  in  the  jieridental  membrane  and  tiabeeula?   (original). 


FlGlTlE  74. 

Shows  the  root  of  the  tooth,  the  peridental  membrane,  active  inflammation  in  the 
trabecnte  and  the  formation  of  two  abscesses.  Xote  that  both  these  abscesses  are 
located  in  what  was  once  the  alveolar  process.  The  peridental  membrane  can  be 
readily  observed  between  the  root  of  the  tooth  and  the  nearest  abscess  (or- 
iginal). 


RESEARCHES    ON    HUMAN    IN    PERICEMENTITIS.  181 

The  preceding  three  illustrations  show  the  different  stages  of 
inflammation  and  liquefaction  of  the  peridental  membrane  of  the 
right  superior  first  molar  in  a  forty-year-old  lady,  a  marked 
neurasthenic  who  has  had  periostitis  and  interstitial  gingivitis 
with  pyorrhoea  alveolaris  for  the  last  twent}^  years  and  is  now 
losing  her  teeth  very  rapidly.  Fig.  72  shows  a  cross-section  of 
palatal  root  near  the  apex,  showing  active  inflammation  in  the 
peridental  membrane.  The  round  cell  inflammation  with  exudate 
is  rapidly  collecting  between  the  bundles  of  connective  tissue 
fibers.  Fig.  73  is  a  cross-section  of  the  same  root  nearer  the 
apex  showing  connective  tissue  with  active  inflammation,  a  stage 
further  advanced  than  that  of  the  previous  illustration.  In  this 
area  no  fibrous  tissue  can  be  seen.  Fig.  74  shows  a  still  further 
advance  in  degeneration  and  liquefaction,  forming  an  abscess. 
This  is  a  lower  magnification,  showing  a  portion  of  the  two 
buccal  roots  of  the  tooth,  peridental  membrane  and  the  trabeculae 
or  fibrous  tissue  which  was  once  alveolar  process  between  them. 
The  peridental  membrane  may  easily  be  distinguished  around 
each  root  from  the  trabeculae  between  them.  Two  areas  of 
softening  and  liquefaction  may  be  seen  forming  two  abscesses. 


CHAPTER  XVIL 

LOCAL  CAUSES  OF  INTERSTITIAL  GINGIVITIS. 

The  local  irritations  producing  interstitial  gingivitis  are  the 
eruption  of  the  teeth,  change  in  function,  tartar,  uncleanness, 
lactic  acid  ferment,  irritations'  due  to  modern  dentistry,  irreg- 
ular teeth,  regulating  teeth,  implantation  of  teeth. 

Many  years  ago'  I  stated  that  modern  dentistry  was  one  of 
the  most  fruitful  sources  of  interstitial  gingivitis.  Irritations 
from  foreign  substances,  such  as  detached  bristles  of  the  tooth- 
brush, too  great  friction  in  brushing  the  gums  and  alveolar  proc- 
ess, where  the  latter  is  prominent,  injudicious  use  of  the  tooth- 
pick, the  use  of  ligatures  in  holding  in  rubber  dam  and  regulat- 
ing teeth,  regulation  of  teeth  with  any  applicance,  application  of 
the  rubber  dam,  the  use  of  clamps,  crown  and  bridge  work,  irri- 
tation and  heat  due  to  artificial  dentures  and  regulation  plates, 
overlapping  fillings,  injuries  from  instruments,  the  devitaliza- 
tion of  pulps,  root  fillings  which  throw  increased  work  upon  the 
peridental  membrane  or  irritate  it,  in  a  word  whatever  irritates 
the  gum  margin,  peridental  membrane  or  alveolar  process,  is 
likely  to  produce  inflammation  which  later  becomes  chronic.  I 
am  convinced  that  the  disease  is  contagious,  or  progressive,  not 
from  one  individual  to  another,  but  from  one  tooth  to  another  in 
the  same  mouth. 

The  greatest  and  most  important  local  cause  of  interstitial 
gingivitis  is  that  of  the  eruption  of  the  teeth  since  nearly  every 
person  possesses  two  sets. 

Tooth  eruption  of  both  the  first  and  second  set  ushers  in  the 
second  and  third  periods  of  stress.  It  is  at  these  periods  when 
great  changes  take  place  in  the  system  of  the  child  and  mark 
the  early  eras  of  future  welfare.  The  absorption  of  bone  in  the 
eruption  of  the  teeth  and  the  Ijuilding  up  of  bone  about  the  roots 


1  Talbot,  The  Dental  Cosmos,  Nov.  1886. 


LOCAL  CAUSES   OF  INTERSTITIAL  GINGIVITIS.  183 

to  hold  tliem  in  place  is  an  inflammatory  process.  How  well  this 
is  accomplished  depends  upon  the  health  of  the  child.  In  neu- 
rotic and  degenerate  children,  when  the  nervous  system  is  un- 
stable and  the  child's  vitality  is  of  low  order,  the  process  of 
absorption  and  deposition  of  bone  cells  is  not  carried  on  nor- 
mally. Especially  is  this  true  in  the  building  up  of  the  alveolar 
process  about  the  roots  of  the  teeth.  Interstitial  gingivitis  re- 
mains in  the  alveolar  process  to  a  greater  or  lesser  extent  during 
the  entire  period  of  and  until  the  shedding  of  the  first  set  of 
teeth.  The  extreme  illustrations  of  this  disease  are  those  con- 
nected with  rachitis,  infantile  scurvy,  inherited  syphilis,  marked 
neurosis,  degeneracies  and  similar  diseases.  The  jaws  are  often 
small,  the  alveolar  processes  are  undeveloped  and  quite  loosely 
built  up.  The  gums  are  always  inflamed  and  frequently  ulcer- 
ated. At  the  second  period  of  stress,  when  the  first  teeth  are 
erupting  the  entire  alimentary  canal  as  well  as  all  the  internal 
organs  undergoes  changes  in  preparation  for  the  reception  of 
solid  starchy  food.  The  effects  upon  nutrition  at  this  time  are 
severe.  In  every  patient  there  is  more  or  less  inflammation  in 
the  alveolar  process,  gums  and  peridental  membrane  until  the 
first  teeth  are  shed. 

When  the  second  set  of  teeth  erupt  there  is  a  double  inflam- 
matory process  going  on  in  the  tearing  down  of  the  bone  to 
remove  the  temporary  teeth  and  bailding  up  the  process  for  the 
permanent  teeth.  So  irregular  is  this  action  that  in  many 
mouths  there  is  a  continuous  inflammation  through  the  entire 
process  on  both  jaws.  This  is  noticeable  in  neurotics  and  de- 
generates and  in  those  children  whose  vitality  is  low  and  who 
are  poorly  nourished.  The  bone  is  porous  and  loosely  put  to- 
gether. The  severity  of  interstitial  gingivitis  during  the  erup- 
tion of  both  sets  of  teeth  and  after  all  of  the  second  teeth  are  in 
the  mouth  wdll  depend  upon  the  nervous  system  and  blood  sup- 
ply. It  must  not  be  lost  sight  of,  that,  after  all  of  the  second  set 
of  teeth  are  in  the  mouth,  there  is  a  restlessness  existing  among 
them  till  all  are  securely  located  in  their  respective  localities, 
although  they  may  not  be  in  their  proper  relations  to  each  other. 
As  long  as  this  restlessness  continues,  and  it  may  persist  until 
middle  life,  interstitial  gingivitis  is  always  present.     The  irri- 


184  INTERSTITIAL    (!IN(iIVITIS. 

tatioii  set  up  by  the  Mclvancing  teetli  causes  inflammation  iu  tlie 
gums  and  alveolar  process.  A  visit  to  schools  for  defective  chil- 
dren and  an  examination  of  their  mouths  will  convince  any  one 
of  the  truth  of  this  statement. 

CHANGES    IN    FUNCTION. 

Change  in  function  has  been  discussed  in  a  general  way  in 
previous  chapters.  It  is  necessary,  however,  to  state  here  that 
owing  to  use  and  disuse  of  structures  and  environment,  the  func- 
tion of  mastication  is  gradually  being  reduced  to  a  minimum. 
On  this  account  and  the  gradual  reduction  of  the  size  of  the  jaws 
and  straight  crowned  teeth,  the  alveolar  process,  has,  in  most 
persons,  changed  its  shape  and  has  become  narrow,  long  and 
thin.  This  change  in  shape  and  loss  in  blood  and  nerve  supply 
makes  the  process  about  one  or  more  teeth  exceedingly  suscep- 
tible to  disease  and  destruction  on  account  of  loss  of  function. 

TARTAE. 

Tartar  is  the  excess  of  lime  salts  in  the  blood  excreted 
through  the  salivary  glands.  It  remains  soluble  in  the  saliva 
until  it  reaches  the  mouth  cavity  when  it  precipitates.  Just  how 
precipitation  is  accomplished  has  not  been  proven  beyond  a 
doubt.  One  theory  is  that  the  action  of  ammonia  exhaled  from 
the  lungs  is  the  greatest  factor. 

Kirk  says,'  "As  the  saliva  contains  carbon  dioxid  in  solution 
it  has  been  assumed  with  some  justification,  that  the  escape  of 
the  carbon  dioxid  wdiich  was  the  solvent  of  the  calcium  carbonate 
and  tricalcic  phosphate,  causes  a  precipitation  of  those  salts  in 
the  presence  of  the  colloid  mucin,  in  comlnnation  with  which  it 
deposits  as  tartar  upon  the  teeth." 

H.  H.  Bouchard'  proposed  an  explanation  for  the  formation 
of  .salivary  tartar  deserving  of  consideration,  viz.,  ''that, 
inasmuch  as  fermentative  processes  in  the  oral  cavity  give  rise 
to  acids,  and  particularly  lactic  acid,  these  acids  cause  precipi- 
tation of  the  mucin  of  the  saliva  as  a  coagulnm  which  entangles 
in  its  structure  calcic  phosphate  and  carbonate,  and  this  mass  by 


2  Kirk.     American  Text-Book  of  Operative  Dentistry,  page  480. 

3  See  Origin  of  Salivary  Calculus  by  Henry  H.  Bouchard,  Dental  Cosmos.  1895, 
vol.  XXVII,  page  821.  Also  Varieties  of  Dental  Calculi,  by  the  same  author,  Dental 
Cosmos,  1898,  vol.  XL,  page  1. 


LOCAL  CArSES   OF  IXTERSTITL\L   GINGIVITIS.  185 

gradual  condensation  increases  in  density  to  the  extent  of  form- 
ing the  coherent  deposit  known  as  tartar." 

Tartar  accunndations  vary  in  quantity  as  well  as  in  charac- 
ter in  each  individual  and  even  in  the  same  mouth.  In  some  the 
greatest  amount  is  found  upon  the  molar  teeth  in  opposition  to 
the  parotids  whose  function  is  apparently  to  keep  the  mouth 
moist.  These  glands  constantly  discharge  small  quantities  of 
saliva  without  food  stimulation.  Owing  to  its  special  function, 
the  sub-maxillary  gland  is  stimulated  by  tasteful  substances, 
hence  probably  does  not  send  out  as  much  lime  salts.  The  sub- 
lingual glands  next  to  the  parotids  discharge  the  greatest  amount 
of  calcic  salts,  which  accounts  for  the  quantity  of  deposit  found 
on  the  posterior  surface  of  the  inferior  incisors.  The  tartar  will 
accumulate  so  rapidly  in  some  mouths  as  to  completely  cover  a 
tooth  or  teeth  in  a  short  time.  In  some  autotoxic  states  there  is 
always  excess  of  tartar  deposit.  In  a  patient  in  whom  mal- 
nutrition was  most  pronounced,  deposits  of  tartar  would  collect 
so  rapidly  as  to  cover  all  the  teeth  in  from  four  to  six  weeks. 
The  teeth  were  of  a  degenerate  type  in  that  they  had  no  enamel. 

In  tartar  analysis  there  is  also  great  variation,  that  deposited 
near  Steno's  duct  having  the  greater  per  cent  of  lime  carbonate 
while  that  from  the  lower  incisors  has  the  greater  per  cent  of 
lime  phosphate. 

Tartar  may  be  black,  deep  biown,  green  or  yellow.  In  to- 
bacco users  the  deposit  is  usually  black,  presumably  stained 
from  nicotine.  Other  agents  will  stain  tartar  as  well.  This  is 
finely  exampled  in  betel-nut  chewers  where  "the  rapid  accunni- 
lation  of  large,  dense  deposits  of  tartar  which  at  first  are  red, 
then  finally  become  a  dark,  chestnut  brown  or  black."'  Nodules 
of  tartar  which  cling  with  such  persistency  to  the  roots  of  the 
teeth  are  usually  of  a  greenish  or  dark  brown  color  and  of  great 
density.  Tartar  is  not  uncommon  in  domestic  animals  and  the 
wild  in  captivity.  I  have  no  means  of  ascertaining  whether  wild 
animals  running  at  large  are  thus  alfected. 

If  the  deposits  of  tartar  are  allowed  to  remain  upon  the 
teeth,  they  are  added  to  day  by  day.     Sooner  or  later,  they  set 


*  Kirk.     American  T'ext-Book  of  Operative  Dentistry. 


186  INTERSTITIAL   GINGIVITIS. 

np  irritation  and  inflammation  in  the  gnms,  in  tlie  peridental 
membrane  and  in  tlie  alveolar  process,  with  resulting  interstitial 
gingivitis,  pyorrluca  alveolaris  and  finally  exfoliation  of  the 
tooth  or  teeth. 

IRREGULAR   TEETH. 

Every  one  is  familiar  with  the  fact  that  those  persons  who 
possess  small  jaw^s  and  irregular  teeth  are  more  subject  to  inter- 
stitial gingivitis  than  those  persons  possessing  normal  jaws  and 
teeth.  This  is  due  first  to  the  fact  that  those  persons  possessing 
irregular  teeth  have  unstable  nervous  systems.  Second,  the  ir- 
regularity of  the  teeth  brings  the  roots  closer  together,  making 
the  alveolar  process  thin  between  the  roots,  thus  reducing  the 
blood  and  nerve  supply,  and  thus  reducing  resistance.  The  gums 
are  inflamed  from  want  of  cleanliness  and  proper  brushing  and 
the  function  of  proper  mastication  is  lost.  The  gums  thicken 
because  engorged  with  blood  and  stasis  takes  place,  resulting  in 
irritation. 

UNCLEANLINESS. 

One  of  the  most  fruitful  sources  of  interstitial  gingivitis  is 
uncleanliness.  Food  and  tartar  collect  on  the  teeth  at  the  gin- 
gival border  setting  up  irritation  and  inflammation.  A  want  of 
proper  measures  for  cleaning  the  teeth  and  gum  margins  after 
each  meal  soon  allows  the  accumulation  to  irritate  the  gums 
which  become  inflamed  and  the  food  works  its  way  along  the 
roots  of  the  teeth.  The  gums  become  inflamed,  swollen  and  de- 
tached from  the  necks  of  the  teeth.  This  condition  allows  more 
food  and  filth  to  collect  which  decomposes  and  forms  lactic  acid. 
This  in  turn  also  irritates  the  gums  and  further  inflammation 
follows. 

IRRITATIONS    DUE    TO    MODERN    DENTISTRY. 

In  my  researches  on  interstitial  gingivitis  many  years  ago," 
I  called  the  attention  of  the  profession  to  the  fact  that  modern 
dentistry  was  producing  more  inflammation  of  the  gums,  peri- 
dental membrane  and  alveolar  process  than  any  one  cause. 
These  irritations  were  most  noticeable  at  that  early  period  about 


5  Talbot.     The  Dental  Cosmos,  Nov.  1886. 


LOCAL   CAUSES   OF   INTERSTITIAL   OUSTGIVITIS.  187 

those  teeth  which  had  been  "immediately  separated  for  filling," 
so  commonly  practiced  by  the  older  members  of  our  profession 
before  the  rubber  dam.  A  piece  of  orangewood  made  V-shaped, 
with  the  base  resting  upon  the  gum  margin,  was  forcibly  driven 
between  the  teeth  for  the  purpose  of  obtaining  plenty  of  room 
for  immediate  filling  and  also  to  press  forcibly  against  the  gums 
and  alveolar  process  to  jjrevent  the  gums  from  weeping,  thus 
keeping  the  cavity  dry.  In  the  majority  of  cases  so  treated, 
interstitial  gingivitis  was  set  up  which  in  time  became  chronic. 

The  inflammation  continued  and  followed  the  root  upon  one 
side  oftentimes  to  the  apex.  The  alveolar  process  became  de- 
stroyed on  the  side  of  the  inflammation  and  not  infrequently 
pus  infection  would  follow.  The  tooth  would  sometimes  rotate 
upon  itself  or  move  in  one  direction  or  the  other  out  of  its  posi- 
tion. The  most  excruciating  pain  accompanied  the  malleting 
of  these  wedges  into  place. 

The  modern  method  of  rapid  wedging  with  separators  is  only 
a  modification  of  this  barbarous  method  of  procedure  and  is  fre- 
quently the  source  of  interstitial  gingivitis  and  later  pyorrhoea 
alveolaris. 

Wedging  teeth  by  any  method  sets  up  inflammation  which 
may  or  may  not  be  restored  to  normal.  In  any  event,  if  poisons 
circulate  in  the  blood  later  in  life,  such  irritated  or  inflammatory 
localities,  owing  to  the  transitory  nature  of  the  structures,  are 
the  first  to  be  affected  by  chronic  interstitial  gingivitis,  since 
these  structures  have  already  been  previously  involved  in  struc- 
tural changes. 

CONDENSING  GOLD  WITH  THE  MALLET. 

The  excessive  use  of  the  mallet  which  was  necessary  to  build 
out  teeth  in  those  early  days  assisted  greatly  in  producing  in- 
flammation of  the  peridental  membrane  and  alveolar  process  in 
connection  with  the  rapid  wedging.  I  recall  a  number  of  in- 
stances in  my  early  practice  where  interstitial  gingivitis  and 
absorption  of  the  alveolar  process  occured  in  neurotic  children, 
the  result  of  malleting  in  large  gold  fillings.  These  cavities  w^ere 
usually  located  in  first  permanent  molars  and  sometimes  in  the 


188  INTERSTITIAL    (iIN(iIVITIS. 

bicuspid.     Absorption   of  the  alveolar  process  took  place,  the 
teeth  became  loose  and  (lrop})ed  out  or  were  extracted. 

At  the  present  time  malleting  in  lar^^e  gold  fillings  in  chil- 
dren's teeth,  especially  in  neurotic,  sypliilitic,  rachitic  and  sim- 
ilar children  should  be  avoided  on  this  account.  The  nerve 
strain,  under  such  barbarous  treatment,  is  very  great  and  the 
boy  or  girl  suffering  from  such  constitutional  conditions  should 
be  exempt  from  such  procedure. 

GOLD  CROWNS. 

When  gold  crowns  were  first  introduced  about  1880,  the 
method  of  attachment  was  to  drive  the  cutting  edge  of  the  gold 
to  the  alveolar  process  and  disastrous  results  immediately  fol- 
lowed. Infiammation  set  in  and  destruction  of  the  alveolar 
process,  with  exfoliation  of  the  tooth,  soon  followed.  Since  that 
time  we  have  learned  that  gold  crowns  extending  under  the  free 
margin  of  the  gums  will  set  up  acute  inflammation  which  after- 
wards becomes  chronic  and  destruction  of  the  alveolar  process  is 
sure  to  follow. 

BRIDGEWORK. 

When  a  bridge  is  placed  upon  two  or  more  roots  the  function 
of  those  teeth  has  been  destroyed.  The  teeth,  owing  to  the  elas- 
ticity of  the  peridental  membrane,  are  allowed  to  yield  slightly 
when  pressure  is  applied  in  mastication.  When  they  are  bridged, 
they  become  rigid  and  the  force  of  the  impact  in  mastication 
irritates  the  membrane  which  together  with  autointoxication  sets 
up  further  irritation  and  inflammation  and  absorption  of  the 
bone  takes  place.  The  collection  of  filth  under  bridgework  is  also 
a  fruitful  source  of  inflammation.  Particles  of  food  find  lodge- 
ment under  bridges  and  can  not  be  dislodged  by  either  tooth 
brush  or  toothpick. 

DEVITALIZING  THE  PULPS  OF  THE  TEETH. 

Destroying  the  pulps  of  the  teeth  and  filling  the  roots  throw 
extra  work  upon  the  peridental  membrane.  This  extra  work 
changes  the  normal  function  of  the  tissues.  Poisons  circulating 
in  the  blood  cause  an  inflammatory  process  to  first  attack  such 
teeth  and  rapid  inflammation  and  absorption  occur. 


LOCAL   CAUSES   OF   INTEESTITIAL   GJINGIVITIS.  189 

CAVITIES  IN  TEETH  AND  OVEELAPPING  FILLINGS. 

Cavities  at  the  margin  of  the  gums  and  fillings  with  rough 
edges  irritate  the  soft  tissues  and  cause  inflammation  followed 
by  absorption. 

1,IGATURES    AND    CLAMPS. 

Ligatures  and  clamps  for  holding  the  rubber  dam  not  infre- 
quently irritate  the  gums  and  set  up  inflammation. 

ARTIFICIAL    DENTURES. 

Partial  plates  of  any  description  for  artificial  dentures  or 
regulating  plates  act  as  foreign  bodies  against  the  mucous  mem- 
brane and  gums,  producing  irritation  by  heat,  by  the  accumula- 
tion of  foreign  substances  beneath  them  and  the  edge  of  the  plate 
will  irritate  the  gums  about  the  teeth,  thus  setting  up  inflamma- 
tion. 

INSTRUMENTS. 

Not  infrequently  instruments  used  in  excavating  cavities,  fin- 
ishing fillings,  etc.,  will  irritate  the  gum  tissue  which  will  later 
set  up  inflamnuition,  absorption  and  finally  destruction  of  the 
process. 

EXCESSIVE  BRUSHING. 

It  is  not  uncommon  to  find  teeth  located  on  the  external  sur- 
face of  the  alveolar  process.  This  occurs  in  those  patients  in 
whom  the  jaws  are  small  for  the  long  diameter  of  the  teeth.  The 
teeth  in  erupting  will  force  their  way  into  place  and  when  in 
their  normal  condition  the  dental  arch  is  located  upon  the  outer 
border  of  the  alveolar  process. 

In  such  patients  the  bone  over  the  roots  of  the  teeth  on  the 
outside  is  often  as  thin  as  writing  paper,  while  it  is  very  thick 
upon  the  palatine  and  lingual  side  of  the  jaw.  It  is  not  uncom- 
mon to  find  the  cuspid  tooth  located  toward  the  outer  side  of  the 
alveolar  process  whih'  all  the  other  teeth  are  in  their  proper 
places.  The  nerve  and  blood  supply  is  almost  nil,  resistance  or 
restoration  is  out  of  the  question. 

Under  such  conditions  too  great  stimulation  by  the  tooth 
brush  causes  inflammation  and  absorption  of  the  outer  plate  of 
bone,  which  in  tinre  will  expose  the  roots  of  the  teeth. 


190  INTERSTITIAL    GINGIVITIS. 

PICKING    THE    TEETH. 

The  constant  use  of  the  toothpick,  irritating  the  gum  margin, 
is  a  fruitful  source  of  interstitial  gingivitis.  This  simple  pro- 
cedure is  a  spendid  illustration  of  the  effect  of  slight  irritation 
producing  inflammation  of  the  gum  which  later  becomes  chronic 
with  eventual  destruction  of  the  alveolar  process. 

REGULATING  TEETH. 

One  of  the  most  prolific  sources  of  interstitial  gingivitis  is 
the  regulation  of  teeth.  When  we  consider  the  nature  of  the 
alveolar  process  and  what  it  is  obliged  to  undergo  by  the  time  the 
permanent  teeth  have  erupted  and  the  sensitive  condition  in 
which  it  is  placed  as  a  transitory  structure  and  end  organ,  after 
the  permanent  teeth  are  in  place,  together  with  the  unstable 
nervous  system  of  the  patient,  as  well  as  the  age  at  which  this 
operation  must  be  performed,  the  wonder  is  that  after  the  oper- 
ation is  complete  there  is  any  process  left. 

The  pressure  necessary  to  move  the  teeth  sets  up  an  inflam- 
mation to  produce  the  entire  destruction  of  bone  in  line  of  pres- 
sure. A  third  set  of  teeth  in  our  present  phylogenic  development 
is  unnecessary  and  therefore  nature  is  ill  prepared,  especially 
in  neurotic  children  with  unstable  nervous  systems,  to  again 
build  up  the  alveolar  process  about  the  teeth.  The  degree  to 
which  the  alveolar  process  wall  be  restored  will  depend  upon  the 
condition  of  the  nervous  system,  the  blood  and  the  age  of  the 
patient.  If  the  patient  is  poorly  nourished  so  that  material  (lime 
salts)  is  insufficient  or  the  nerve  supply  to  the  part  is  unstable 
or  the  patient  has  obtained  his  growth,  the  process  is  liable  to  be 
deficient  in  structure. 

This  deficiency  in  structure  is  easily  demonstrable,  in  persons 
of  middle  age  or  of  later  life  who  have  had  teeth  extracted,  and 
a  part  of  the  alveolar  process  has  come  away.  By  frequent  ob- 
servation it  will  be  seen  that  the  process  is  not  restored  although 
the  periosteum  is  still  present.  Again  after  the  extraction  of  a 
tooth,  although  the  alveolar  process  remains  normal  about  the 
adjoining  teeth,  a  slight  absorption  of  the  edges  of  the  alveolus 
about  the  cavity  will  take  place.  The  gums  heal  over  the  wound. 
By  the  use  of  a  broken  excavator,  sharpened  in  a  direct  line  with 


LOCAL  CAUSES   OF  INTEESTITIAL   GINGIVITIS.  191 

the  shaft  at  the  point,  this  may  be  readily  passed  through  the 
soft  fibrous  tissue  of  tlie  once  root  cavity.  Years  after  the  ex- 
traction, fibrous  tissue  without  lime  salts,  is  present.  The  same 
is  true  when  abscesses  have  formed.  The  fibrous  tissue  is  re- 
stored but  not  the  bone  substance.  Regulating  teeth  should  be 
performed  before  the  patient  has  obtained  his  growth  and  with 
as  little  movement  of  the  teeth  as  possible  to  obtain  fairly  good 
results.  The  indiscriminate  spreading  of  the  dental  arch  with- 
out extraction  should  be  discouraged.  The  excessive  inflamma- 
tion set  up  throughout  the  entire  alveolar  process  for  the  pur- 
pose of  enlarging  the  dental  arch  and  thus  bringing  all  teeth  into 
line  is  liable  to  endanger  the  restorative  process. 

I  have  a  record  of  forty-two  patients  in  whom  the  teeth  re- 
mained loose  from  a  want  of  deposition  of  bone  cells  to  hold  them 
in  position  and  in  whom  the  roots  of  the  teeth  were  exposed  to 
a  greater  or  lesser  extent.'  Interstitial  gingivitis  is  always  pres- 
ent and  occasionally  pyorrhoea  alveolaris.  The  esthetic  effect 
of  the  large  dental  arches  associated  with  a  small  face  is  not  in 
harmony  with  good  judgment. 

The  nerve  strain,  the  inartistic  appearance  and  excessive  in- 
flammation should  be  reduced  to  a  minimum  by  adopting  such 
measures  as  are  necessary  to  perform  the  operation  as  quickly  as 
possible  with  as  little  nerve  strain  and  with  the  least  amount  of 
work,  to  avoid  interstitial  gingivitis. 

The  removal  of  bone  in  front  of  the  advancing  tooth  or  teeth 
with  a  burr  (as  I  have  recommended)  will  save  time,  prevent 
undue  inflammation,  pain,  nerve  strain,  and  absorption. 

PLANTATION  OF  TEETH. 

Plantation  of  teeth  consists  of  two  methods.  One  the  re- 
placing of  a  tooth  into  the  ca\T.ty  from  which  it  has  been  acci- 
dentally removed  or  a  similar  tooth  has  been  taken  from  the 
mouth  of  another  person,  while  the  other  is  the  insertion  of  a 
foreign  tooth  either  into  an  enlarged  natural  socket  or  into  an 


G  A  young  woman  tineteen  years  of  age  called  at  my  office  for  advice  in  regard 
to  the  restoration  of  the  alveolar  process  about  the  six  anterior  inferior  teeth. 
The  bone  had  been  destroyed  in  regulating.  Retaining  bands  had  been  in  place 
about  two  years.  The  oiierator  was  afraid  to  remove  the  bands  for  fear  that 
the  teeth  would  drop  out.     It  was  impossible  to   restore  the  process. 


192  INTERSTITIAL  GINGlIVITIS. 

artificial  alveolus  wliicli  has  been  made  for  its  reception.     The- 
replaiitation  of  a  tooth  which  has  been  forcibly  removed  in  a 
healtliy  growing  child  in  most  cases,  if  skillfully  performed 
under  aseptic  conditions,  will  return  to  a  normal  condition  with- 
out chronic  infianunation. 

On  the  other  hand,  from  what  we  have  learned  from  the  un- 
stable nature  of  the  alveolar  process  and  the  many  difficulties 
associated  therewith,  we  hardly  expect  many  favorable  results 
by  the  enlargement  of  natural  sockets  or  the  formation  of  new 
sockets.  By  these  operations  the  peridental  membrane  is  de- 
stroyed in  the  one  case  and  not  present  in  the  other.  Interstitial 
gingivitis,  with  lacunar  absorption  of  the  root  (which  is  a  foreign 
body)  takes  place  or  absorption  of  the  alveolar  process  by 
halisteresis  ensues  or  both  with  the  eventual  loss  of  the  tooth. 

If  the  patient  has  obtained  his  growth,  the  chances  of  success 
are  hardly  to  be  expected.  Especially  is  this  true  if  the  patient 
has  autointoxication  or  other  poisons  in  the  blood  or  is  subject 
to  disease  of  any  of  the  eliminating  organs. 

There  are  many  other  irritants,  both  constitutional  and  local, 
not  mentioned  by  the  author.  Enough  have  been  cited,  however, 
to  give  the  reader  a  fair  idea  of  the  influence  of  these  irritants 
upjon  the  alveolar  process. 

When  inflammation  is  once  established  in  the  gums  or  alve- 
olar process  by  local  or  constitutional  conditions,  it  is  usually 
progressive  as  far  as  the  exfoliation  of  the  tooth.  If,  however, 
the  inflammation  is  circumscribed  and  does  not  extend  entirely 
around  a  tooth  which  has  one  root,  or,  if  only  one  root  of  a  molar 
is  involved,  the  inflannnatory  process,  with  absorption  will  have 
a  limited  area  and  extend  only  on  one  side  of  a  single  root  or 
may  involve  only  the  one  root  of  a  molar  tooth.  This  inflamma- 
tion and  absorption  will  progress  to  the  end  of  the  root.  In  other 
words,  the  disease  is  progressive  after  it  has  become  established 
although  treatment  both  local  and  constitutional  may  to  a  certain 
limit  retard  its  progress.  Illustrations  of  this  may  be  recalled 
in  those  teeth  which  have  been  violently  wedged  apart  to  obtain 
room  for  filling  and  the  inflammation  extends  along  one  side  of 
a  tooth,  or,  when  gold  crowns  have  been  carried  under  the  gums 


LOCAL   CAUSES   OF   INTERSTITIAL    GINGIVITIS.  193 

and  irritation  has  set  up  uniformly  around  the  tooth,  or,  in  teeth 
which  have  too  much  pressure  in  mastication,  or,  in  those  teeth 
for  which  there  are  no  opposing  teeth.  The  progressive  nature 
of  inflammation  and  absorption  is  due  to  the  endo-t.ransitory 
nature  of  the  process. 


CHAPTER  XVIII. 

CONSTITUTIONAL  CAUSES   OF  INTERSTITIAL   GINGIVITIS. 

Pathological  changes  in  the  structure  and  function  of  the 
human  body,  in  a  more  or  less  severe  form,  are  due  to  constitu- 
tional affections.  Sometimes  they  are  the  result  of  local  diseases 
of  certain  organs,  or  the  disease  may  have  general  character- 
istics from  the  first  and  still  may  affect  certain  individual  organs, 
hence  in  this  way  secondary  diseases  are  developed.  This  has 
been  particularly  borne  out  in  trauma,  intoxications,  contagious 
infections  and  some  tumor-like  forms. 

Diseases  are  designated  as  acute  and  chronic.  Acute  dis- 
eases are  those  of  short  duration.  The  acute  stage  may  be  ter- 
minated promptly  in  recovery  or  death  or  it  may  be  prolonged  in 
the  chronic  period.  Disease  may  occur  with  or  without  reducing 
the  tonicity  of  the  body  as  a  whole  or  a  part. 

Fever  is  a  general  metabolic  disturbance,  characteristic  of 
many  acute  infections  and  autointoxications.  The  most  impor- 
tant indication  is  a  rise  in  the  temperature  of  the  body.  The  su- 
perficial temperature  of  a  man  normally  varies  considerably  but 
the  internal  degree  of  heat  is  nearly  constant.  According  to  the 
researches  of  Jurgensen,  Ziemssen  and  Krabler'  the  minimum 
internal  degree  of  heat  is  during  the  early  morning  hours  and 
the  maximum  is  reached  at  about  five  o  'clock  in  the  afternoon. 

In  pyrexia,  along  with  an  increased  production  of  heat,  there 
is  also  an  increase  of  nitrogenous  metabolic  products  excreted 
in  the  urine.  In  regard  to  heat  the  amount  thrown  off  varies ; 
thus  in  the  early  stages  of  fever  when  the  internal  temperature 
is  increasing,  the  surface  temperature  is  below  normal  with  con- 
tracted vessels  and  the  amount  of  heat  dissipation  is  lessened. 
Since  the  skin  produces  but  a  small  amount  of  heat,  its  warmth 
is  dependent  upon  the  heat  brought  from  the  interior  of  the  body. 


1  Thoma,  Text-Book  of  General  Pathology. 


CONSTITUTIONAL  CAUSES  OF  INTERSTITIAL  GINGWITIS.  195 

SO  if  the  skin  vessels  contract,  the  amount  of  blood  that  flows  to 
the  surface  is  lessened  and  the  temperature  of  the  skin  falls. 

The  lessened  amount  of  heat  thrown  off  together  vntli  the 
greater  production  causes  a  rise  \\T.thin  the  body,  although  aside 
from  a  slight  feeling  of  cold,  there  may  be  no  apparent  change 
in  temperature.  But  if  there  is  marked  contraction  of  the  skin 
vessels,  the  chilliness  is  more  pronounced,  so  much  that  there 
may  be  violent  shivering  of  the  trunk,  limbs  and  chattering  of 
the  teeth.  The  violent  contraction  of  the  skin  muscles  produces 
heat.  When  the  fever  is  at  its  highest,  the  contracted  cutaneous 
vessels  yield,  the  skin  becomes  abnormally  dry  and  hot,  while 
the  internal  temperature  remains  high  also.  When  the  fever  sub- 
sides, the  temperature  falls  and  the  skin  becomes  moist,  or  there 
may  be  an  excessive  amount  of  sweat. 

Other  symptoms  of  pyrexia  aside  from  temperature  rise  are 
malaise,  headache,  thirst,  rapid  pulse  and  respiration,  digestive 
disturbance  and  decrease  in  the  amount  of  urine  secreted  and 
passed  with  abnormal  urinary  acidity  and  oftentimes  indican. 
In  digestive  disturbance,  primarily,  there  is  loss  of  appetite,  ex- 
cessive thirst,  the  salivary  secretions  are  restricted  and  the 
entire  alimentary  tract  becomes  so  atfected  as  to  prevent  normal 
absorption  from  the  stomach  and  intestine.  The  digestive  and 
metabolic  disturbance  may  be  less  than  is  usually  assumed.  Ex- 
periments show  that  in  typhoid  the  digestion,  absorption  and 
utilization  of  food  may  be  complete. 

In  a  search  for  the  connecting  etiology  of  these  fever  symp- 
toms we  must  first  take  into  consideration  the  infections  and  in- 
toxications from  which  they  are  derived.  Disease  producing 
germs,  by  their  poisons  when  they  enter  the  blood,  cause  fever. 
It  may  be  that  many  substances  produced  l)y  the  metabolism  of 
the  human  body  have  similar  action.  There  are  also  poisonous 
agents  not  derived  from  microbes  which  cause  temperature  rise. 

Fever  appears  to  consist  of  two  sets  of  symptoms,  toxemia 
and  pyrexia.  The  first  are  due  to  the  direct  action  on  the  nervous 
system  while  the  second  constitute  a  reaction  on  the  part  of  the 
system  which  tends  at  least  to  neutralize  the  effects  of  the  tox- 
emia. According  to  the  researches  of  Vaughn,  the  poisonous 
substance  is  a  derivative  of  the  albumin  molecule  resulting  from 


196  INTERSTITIAL  GINGIVITIS. 

a  splitting  siicli  as  occurs  in  digestion  or  in  the  destruction  of 
bacteria  by  the  blood  serum  (bacteriolysis).  Thus  certain  veg- 
etable proteins,  like  recin,  jjeptones,  and  the  results  of  the  split- 
ting of  bacterial  proteins  excite  fever.  Metallic  and  alkaloidal 
poisons  do  not,  as  a  rule,  cause  fever  except  by  provoking  in- 
flammation which  results  in  secondary  bacterial  infection.  When 
these  poisons  are  taken  into  the  blood  stream,  a  general  faulty 
metabolism  results  which  gives  rise  to  the  symptoms  just  men- 
tioned. In  regard  to  the  pyrexial  rise  of  temperature,  partic- 
ularly, it  must  be  conceded  that  the  poisons  circulating  in  the 
blood  have  a  disturbing  influence  on  the  structures  of  the  cen- 
tral nervous  system  as  well  as  on  the  vasomotor  system  of  the 
peripheral  nerves.  The  loss  of  heat,  through  the  breath,  is  also 
controlled  by  the  central  nervous  system  which  acts  on  the  fre- 
quency and  depth  of  respiration. 

The  normal  heat  of  the  body  is  produced  by  every  organ  in 
its  metabolism.  The  principal  heat  producing  sources,  however, 
are  the  heart,  muscles  and  principal  abdominal  organs.  The 
energy  of  the  heart  muscle,  when  it  contracts  is  exhibited  partly 
as  heat  and  partly  as  mechanical  work.  The  heat  produced  by 
the  contraction  of  the  heart  is  partly  radiated  into  the  surround- 
ing tissues  and  partly  carried  away  by  the  blood.  In  addition, 
the  mechanical  work  of  the  heart  is  completely  transformed  into 
heat  by  friction  against  the  vessel  walls  and  internal  friction 
within  the  blood  stream.  The  muscles  all  generate  heat  by  their 
action.  The  disturbance  of  assimilation,  digestion  and  absorp- 
tion of  food  occurs  at  the  same  time,  during  fever,  with  temper- 
ature rise.  This  in  turn  causes  metabolic  disturbances  not  only 
of  abnormal  products  but  also  a  breaking  down  of  organic  cells. 
This  may  occur  in  various  organs  and  there  may  appear  any  of 
the  cerebral  disturbances,  such  as  headache,  confusions,  dizzi- 
ness; also  rapid  decay  of  the  teeth,  interstitial  gingivitis;  ab- 
sorption of  the  alveolar  process ;  diseases  and  spontaneous  death 
of  the  pulps  of  the  teeth ;  erosion ;  abrasion  and  discoloration. 
After  fevers,  loss  of  the  hair  and  abnormalities  in  the  nails  usu- 
ally make  their  appearance. 

Degeneration  of  tissues  which  form  the  substance  of  the 
heart,  liver,  kidneys  and  other  structures,  are  partly  due  to  dis- 


CONSTITUTIONAL    CAUSES    OF    INTERSTITIAL    GINGIVITIS.  197 

turbances  of  high  pressure  and  partly  due  to  the  direct  action 
of  poisons  circulating  in  the  blood  which  have  caused  the  fever. 
It  would  not  be  strange,  therefore,  that  similar  degenerations 
occur  as  a  result  of  simple  action  of  poisons  in  non-febrile  acute 
diseases  as  well  as  in  poisoning  by  the  various  inorganic  and 
organic  chemical  substances. 

Chronic  diseases  are  those  of  long  standing  and  are  usually 
the  result  of  a  prolonged  acute  condition.  Generally  there  is  no 
rise  of  temperature  though  there  are  instances  of  pyrexial  and 
apyrexial  periods  alternating. 

In  a  general  way,  I  have  explained  the  cause  of  some  chronic 
diseases,  contagions,  infections  and  intoxications,  but  there  are 
some  constitutional  disorders,  for  example,  chlorosis,  leukaemia, 
rachitis,  obesity,  gout,  diabetes,  osteomalacia  whose  etiology  is 
still  vague,  yet  are  manifested  by  disturbed  metabolism.  Path- 
ologic conditions  to  which  these  diseases  give  rise  are  many  but 
the  two  most  common  are  atrophy  and  malnutrition.  One  of 
the  best  examples  of  atrophy  in  the  human  body  is  the  alveolar 
process.  Atrophy  as  applied  to  the  tissues  and  organs  of  the 
body  is  somewhat  different  in  its  action  on  the  alveolar  process. 
In  all  the  other  tissues  and  organs,  atrophy  means  a  gradual 
wasting  away  of  structure.  While  the  same  condition  takes  place 
in  the  alveolar  process,  in  addition  to  the  wasting  away,  there  is 
total  destruction,  owing  to  the  fact  that  the  process  is  a  doubly 
transitory  structure  and  an  end  organ.  In  the  mouths  of  the  con- 
genital deaf,  dumb,  blind,  feeble-minded  and  delinquent  chil- 
dren, osteomalacia  attacks  the  alveolar  process  before  the 
osseous  system  has  reached  its  growth.  Here,  as  a  consequence 
of  trophic  change,  metabolic  action  and  premature  senility, 
osteomalacia  may  occur  in  connection  with  the  first  set  of  teeth 
at  two  years  or  any  period  thereafter.  When  this  condition 
takes  place  early  in  life,  I  have  called  it '' juvenile  osteomalacia," 
late  in  life  ' '  senile. ' '  - 

It  is  those  organs  of  special  function  which  become  diseased 
and  atrophy  to  the  greatest  extent ;  thus  in  the  liver,  the  cell ;  in 
the  kidney,  the  se'creting  epithelial  cells ;  in  the  heart,  the  muscle 
fibers;  in  the  spleen,  the  pulp  cells;  in  the  subcutaneous  tissue, 


'  Pathogeny  of  Osteomalacia  or  Senile  Atrophy.     The  Dental  Digest,  August,  1903. 


198  INTERSTITIAL    GINGIVITIS. 

the  fat  cells ;  in  the  lungs,  the  stroma  of  connective  tissue  and 
elastic  fibers,  the  blood  vessels  and  epithelial  lining;  in  the  bones, 
including  the  alveolar  process,  the  lamellae;  the  skin  becomes 
thin  and  loses  its  tonicity;  the  epidermis  dry,  cracked  and  scaly; 
the  brain  diminishes  and  the  space  is  filled  cither  by  atrophy  of 
the  skull  or  fluid  in  the  pia-arachnoid. 

Cachexia  is  characteristic  of  organ  degeneration  of  a  chronic 
type.  In  this  condition,  amyloid  degeneration  is  sometimes  as- 
sociated with  albuminous  and  fatty  degeneration  of  the  liver, 
kidney,  heart  muscle,  etc.  The  fatty  tissue  is  lost.  The  epi- 
dermis, unlike  the  marasmic  states,  is  smooth  and  moist.  The 
blood  composition  becomes  changed,  in  many  instances  producing 
capillary  hemorrhage  or  edema.  Then,  too,  the  weight  of  the 
body  and  organs  is  reduced,  showing  that  cachetic  conditions 
are  a  general  disturbance  of  metabolism.  Aside  from  its  chronic 
character  and  absence  of  temperature  variability,  there  are 
many  similar  features  to  those  of  the  pyrexial  disturbances  of 
metabolism. 

ACID  STATES. 

Having  considered  the  more  severe  constitutional  disturb- 
ances in  which  fever  is  always  present,  we  must  now  briefly  con- 
sider those  constitutional  disturbances  so  fatal  to  the  alveolar 
process  and  in  which  fever  does  not  manifest  itself. 

One  of  the  most  common  causes  of  irritation  producing  in- 
flammation and  absorption  of  the  alveolar  process  is  the  acid 
condition  of  the  system.  In  the  human  body  certain  changes  are 
continually  taking  place.  These  changes  take  place  in  the  fluids 
of  the  body  and  are  both  physiologic  and  chemic.  These  changes 
add  to  and  take  away  tissues  of  the  body  and  are  alkaline  or  acid. 
They  are  called  anabolic  when  the  fluids  are  alkaline  and  the  tis- 
sues are  built  up  and  katabolic  when  the  fluids  are  acid  and  the 
tissues  are  broken  down.  The  alkaline  and  acid  states  of  the 
body  may  be  ascertained  by  the  examination  of  the  excretions 
of  the  body.  When  the  fluids  of  the  body  (except  the  gastric 
juice)  have  an  excess  of  acids  the  saliva,  mucus,  perspiration 
and  urine  will  be  excessively  acid.    When  the  secretions  of  the 


CONSTITUTIONAL    CAUSES    OF    INTERSTITIAL    GINGIVITIS.  199 

body  are  acid  it  indicates  that  there  is  a  diminished  alkalinity 
of  the  blood.  This  in  turn  leads  to  improper  functioning  and 
prevents  proper  nutrition  and  produces  lowered  vitality. 

It  is  known  that  an  acid  excess  in  the  system  will  hinder  and 
often  destroy  the  transmission  of  nerve  impulses.  Thus  in  acid 
states  large  areas  of  skin  will  be  without  sensation;  the  knee 
jerk  is  diminished  or  lost  altogether.  A  continued  acid  condi- 
tion of  the  system  mil  cause  nerve  end  degeneration  in  the  pulps 
and  fibrillae  of  the  teeth.  The  teeth  will  discolor,  become  brittle 
and  the  enamel  and  dentine  will  break  off.  In  no  part  of  the 
body  does  the  excessive  acidity  manifest  itself  as  in  the  alveolar 
process.  Its  endo-transitory  nature  makes  it  very  susceptible  to 
irritation  through  its  nerve  filaments  and  its  end  arteries,  set- 
ting up  irritation  and  inflammation.  When  the  fluids  of  the 
body  are  acid  the  alveolar  process  and  mucus  excreted  are, 
therefore,  acid  to  a  greater  or  less  extent,  nutrition  is  thus  cut 
off  and  absorption  of  the  process  takes  place.  Thus  in  acid 
states,  as  well  as  in  dental  states,  the  alveolar  process  gradually 
absorbs  away. 

In  dealing  with  the  influence  of  buccal  states  on  the  constitu- 
tion it  must  be  remembered  that  when  the  elirainatory  system  is 
overstrained,  especially  when  the  poison-destroying  function  of 
the  liver  is  deficient  or  impotent,  the  alveolar  process  and  gums 
play  a  great  part  in  elimination,  whence  come,  for  example,  the 
"blue"  gums  of  lead  poisoning  and  the  "green"  gums  of  brass, 
as  well  as  those  from  mercury,  arsenic,  potassium  iodid,  bromid, 
etc.  Matter  thus  eliminated  is  reabsorbed,  enters  into  the  chyle 
Avith  digested  products,  and  readily  becomes  toxic  to  the  blood 
cells.  That  cachetic  states,  approximating  pernicious  anaemia, 
can  thus  be  produced,  is  clearly  evident.  Were  fecal  anaemia 
existent  before  the  gum  and  alveolar  process  changes  were  set  up 
it  would  thus  be  greatly  intensified.  The  toxemia  producing  this 
gum  and  alveolar  process  state  would  be  greatly  increased 
through  the  overstrain  of  oxidizing  processes  produced  by  re- 
absorption  of  eliminated  products. 

The  toxins  generated  in  the  mouth  readily  pass  into  the  gen- 
eral system.  As. a  result,  chronic  indigestion  with  coexistent 
pigment  spots,  urticaria,  etc.,  may  occur.    Pus  toxins  may  thus 


200  INTERSTITIAL    GINGIVITIS. 

produce  a  sapremia  mimicing  typlioid,  as  pigment  spots  readily 
simulate  the  typhoid  eruption.  In  buccal  manifestations  of  con- 
stitutional disease  the  vicious  circle  of  pathology  peculiarly 
occurs. 

The  alveolar  process  may  be  affected  at  any  period  of  life 
after  the  eruption  of  the  first  set  of  teeth  but  osteomalacia  does 
not  usually  occur  until  the  period  between  twenty-five  and  thir- 
ty-five. Before  this  the  osseous  system  is  in  its  constructive 
state  and  lime  salts  are  being  deposited  rapidly.  Later  in  life 
the  constructive  stage  is  complete  and  material  sufficient  only 
to  repair  waste  is  deposited.  At  the  periods  of  stress  metabolic 
changes  are  most  active — during  puberty  and  adolescence  (four- 
teen to  twenty-five),  during  the  climacteric  (forty  to  sixty), 
when  uterine  involution  in  women  and  prostatic  involution  in 
men  occur  and  finally  during  senility  (from  sixty  upwards), 
when  the  disease  is  always  present  to  a  greater  or  lesser  degree. 
While  in  allied  conditions  men  are  most  influenced,  in  this  dis- 
order the  sexes  seem  to  be  affected  about  equally.  Here  the  in- 
fluence of  pregnancy  comes  into  play.  Pregnancy  disturbs  the 
physiologic  balance  hitherto  existing,  especially  along  the  line  of 
assimilation  and  elimination.  The  well  known  dental  effects  of 
pregnancy  (whose  underlying  cause  affects  the  alveolar  proc- 
ess) are  due  to  this  factor.  This  is  purely  a  constitutional 
affection. 

Among  the  causes  are  non-elimination  of  toxic  substances, 
whether  due  to  autointoxication,  to  bacterial  action,  or  to  me- 
tallic and  vegetable  drugs.  Disorder  or  disease  of  any  excretory 
organ  (kidneys,  bowels,  skin  or  lungs)  will  produce  the  most 
marked  effect,  first  upon  the  constitution  of  the  blood,  and  second 
upon  the  alveolar  process,  with  resultant  osteomalacia. 

The  urine,  as  has  been  shown,  contains  each  day  in  a  normal 
individual  sufficient  toxins  to  cause  death  if  not  excreted.  This 
condition  is  markedly  increased  after  prolonged  nervous  ex- 
plosions like  those  of  epilepsy  or  hysteria.  This  was  pointed 
out  thirty  years  ago  by  Meynert,  who  demonstrated  that  the 
status  epilepticus  (condition  of  rapidly-recurring  convulsions) 
was  due  to  the  accumulations  of  a  proteid  body  in  the  system. 
The  status  epilepticus  is  preceded  by  a  decrease  of  toxins  in  the 


COXSTITUTIOXAL    CAUSES    OF    INTERSTITIAL    GIXGIVITIS.  201 

urine  and  succeeded  l)y  an  increase.  This  is  likewise  true  as  to 
the  influence  of  non-elimination  by  the  other  excretory  organs 
(bowels,  lungs  and  oral  cavity),  as  well  as  to  the  non-exercise 
of  its  poison-destroying  power  by  the  liver.  Xon-elimination 
moreover  interferes  with  ordinary  digestive  functions  and 
hence  increases  its  own  extent.  Another  factor  in  autointoxica- 
tion is  production  of  toxic  products  in  such  quantity  as  to  pre- 
vent destruction  by  organs  like  the  liver  and  consequent  elim- 
ination, since  a  product  to  be  properly  eliminated  must  be 
changed  to  a  particular  chemical  type.  Among  the  factors 
which  affect  both  these  elements  of  elimination  is  the  power 
over  growth  and  repair  exercised  by  the  nervous  system.  In 
part  this  influence  is  exerted  through  control  of  blood  supply  by 
the  vasomotor  nervous  system,  and  in  part  by  that  direct  con- 
trol of  the  nervous  system  over  tissue  change  which  is  known 
as  its  trophic  function. 

Both  influences  are  affected  by  nerve  strain.  Sudden  emo- 
tion may,  as  Bichat  demonstrated  decades  ago,  produce  marked 
defects  upon  bile  secretion  and  may  occasion  jaundice.  Cases 
are  far  from  infrequent  in  which  emotions  like  jealousy  pro- 
duce a  mimicry  of  gall-stone  colic  in  neuropaths.  Murchison, 
Christison  and  Thompson  have  traced  attacks  of  biliary  colic 
to  jealousy.  Other  liver  changes  from  sudden  nervous  disturb- 
ance, whether  of  mental  type  or  not,  are  not  rare.  As  mental 
impressions  are  communicated  to  the  central  nervous  system 
purely  through  mechanical  changes  in  the  nerves,  such  influence 
must  be  purely  material  in  operation.  As  the  brain  exercises  a 
checking  influence  on  the  operations  of  the  liver,  these  mental 
influences  produce  two  effects.  The  mental  shock  increases  the 
checking  action  of  the  central  nervous  system  on  the  local 
ganglia  of  the  liver,  and  destroys  the  checking  action  of  the  liver 
ganglia,  and  in  consequence  these  go  too  fast,  resulting  in  their 
exhaustion.  Either  of  these  conditions  interferes  with  the 
poison-destroying  action  of  the  liver,  and  accumulation  of  waste 
products  is  the  result. 

AVhat  is  true  of  the  liver  is  true  of  the  other  organs.  This 
is  especially  noticeable,  as  Tuke  points  out,  in  regard  to  the 
kidneys.    The  action  of  mental  anxiety  or  suspense,  in  causing  a 


202  INTERSTITIAL    GINGIVITIS. 

copious  discharge  of  pale  fluid,  is  familiar  enough  to  all,  espe- 
cially to  the  medical  student  about  to  present  himself  for  exam- 
ination, the  amount  being  in  a  pretty  direct  ratio  to  his  fear  of 
being  plucked.  The  frequency  of  micturition  may,  however, 
arise  from  nervous  irritability  of  the  bladder  without  increase 
or  even  with  diminished  secretion.  Still  the  action  of  the  skin  is 
usually  checked,  the  extremities  are  cold,  and  the  kidneys  have 
to  pump  off  the  extra  amount  of  fluid  retained  in  the  circulation. 
Elimination  of  the  substance  usually  separated  from  the  blood 
is  diminished  as  compared  mth  the  aqueous  character  of  the 
whole  secretion.  The  odor  may  be  affected  by  the  emotions  in 
man  as  in  animals.  Prout  is  of  the  opinion  that  mental  anxiety 
will  produce  not  only  non-elimination  but  also  change  in  the 
chemical  character,  as  indicated  by  odor  and  otherwise.  Disturb- 
ances in  the  medulla  produce,  as  Claude  Bernard  long  ago 
showed,  a  markedly  pale,  excessive  urine.  These  disturbances 
often  arise  from  intellectual  strain  or  emotional  shock.  The  in- 
fluence of  emotional  states  on  secreting  processes,  and  thereby 
indirectly  upon  autointoxication  states,  is  illustrated  in  the  fact 
long  ago  pointed  out  by  Tuke  that  pleasurable  emotions  increase 
the  amount  of  gastric  juices  secreted,  the  opposite  effect  being 
jjroduced  by  depressing  passions.  Beaumont  found  in  a  case  of 
gastric  fistula  that  anger  or  other  severe  emotions  caused  the 
gastric  inner  or  mucous  coat  to  become  morbidly  red,  dry  and 
irritable,  occasioning  at  the  same  time  a  temporary  fit  of 
indigestion. 

The  influence  of  fear  and  anxiety  on  the  bowels  is  as  well 
marked  as  that  upon  the  bladder  and  kidneys.  Apart  from  mus- 
cular action,  defecation  may  become  urgent  or  occur  involun- 
tarily from  various  causes.  The  increased  secretion  from  the 
intestinal  canal  may  occur  from  fear  and  in  some  cases  from  the 
altered  character  of  the  secretion  itself.  While  in  this  respect 
the  influence  of  fear  may  be  inconvenient  in  man,  it  naturally 
assists  escape  in  some  animals,  as  the  skunk. 

Emotions  powerfully  excite,  modify  or  altogether  suspend,  as 
Tuke  has  shown,  the  organic  functions.  This  influence  is  trans- 
mitted not  only  through  the  vasomotor  nerves  but  through 
nerves  in  close  relation  to  nutrition  and  secretion.     When  the 


CONSTITUTIONAL,    CAUSES    OF    INTERSTITIAL    GINGIVITIS.  203 

excitement  is  of  peripheral  origin  in  sensory  or  afferent  nerves, 
it  excites  tlieir  function  by  reflex  action,  so  that  as  emotion  arises 
it  may  excite  the  central  nuclei  of  such  afferent  nerves,  and  this 
stimulus  be  reflected  upon  the  efferent  nerves,  or  it  may  act  di- 
rectly through  the  latter.  Pleasurable  emotions  tend  to  excite 
the  processes  of  nutrition,  hence  the  excitement  of  certain  feel- 
ings may,  if  definitely  directed,  restore  healthy  action  to  an  af- 
fected part.  Violent  emotions  modify  nutrition.  A^arious  forms 
of  disease  originating  in  perverted  or  defective  nutrition  may 
be  caused  primarily  by  emotional  disturliance.  Emotions,  by 
causing  a  larger  amount  of  blood  to  be  transmitted  to  a  gland, 
increase  sensibihty  and  warmth  and  stimulate  its  function  or 
directly  excite  the  process  by  their  influence  or  nerves  supplying 
the  glands.  Painful  emotions  may  modify  the  quality  (i.  e. 
the  relative  proportion  of  the  constituents)  of  the  secretions. 

Imperfect  elimination  of  effete  matter  from  the  lungs  is  a 
fruitful  source  of  autointoxication.  The  more  marked  forms  are 
those  of  tuberculosis,  in  which  there  is  great  debility  and  in 
which  there  is  greater  waste  than  repair.  Self-poisoning  is  con- 
tinually going  on  and  will  continue  until  death.  The  chest 
capacity  for  the  inhalation  of  pure  air  is  almost  nil,  hence  the 
blood  is  improperly  oxygenated  and  soon  ceases  to  convey 
nutriment  to  the  tissues.  Eight  per  cent  of  criminals  wdio  die 
of  tuberculosis  in  prisons  have  undeveloped  chest  walls.  De- 
generacy therefore  cuts  quite  a  figure  in  the  role  of  autointoxi- 
cation. Degenerates  with  contracted  chest  walls  are,  however, 
more  frequently  found.  Many  undeveloped  individuals  in  every 
w^alk  of  life  for  this  reason  have  tuberculosis.  Peojjle  with  un- 
developed chest  walls  and  chest  capacity  may  not  have  tuber- 
culosis and  yet  may  suffer  from  autointoxication.  Those  who 
have  had  pneumonia  with  adhesion;  and  who  are  thus  unable 
to  oxygenate  the  blood,  are  subject  to  this  disease.  Asthmatics 
and  hay-fever  patients  suffer  from  autointoxication  and  alveolar 
absorption.  When  the  skin  is  overstrained  as  to  excretion 
through  kidney  .and  bowel  overstrain,  the  lungs  are  forced  to 
take  on  increased  work  with  imperfect  oxygenation  as  a  result. 
This  is  noticed  in  the  odor  of  the  breath  in  Bright 's  disease  and 
in  the  air-hunger  of  diabetes,  etc.     In  nerve-strain  states  and 


204  INTERSTITIAL    GINGIVITIS. 

in  the  condition  described  by  Albu  not  only  do  excretory  organs 
suffer  but  the  secretions  of  those  glands  like  salivary  and  buc- 
cal glands  are  so  altered  as  to  become  irritants.  These  ex- 
cretory conditions  not  only  result  upon  autointoxication  states 
but  are  modified  by  trophic  nerve  function  alterations.  By 
trophic  changes  are  meant  such  tissue  alterations  as  occur  in 
morbid  conditions  from  disordered  function  of  the  centers  of 
nutrition.  Peripheral  as  well  as  central  may  be  involved.  The 
well  known  law  of  Wallerian  degeneration  of  nerve  fibers  is  an 
illustration,  the  posterior  ganglion  acting  as  a  trophic  center 
for  the  fibers  of  the  posterior  root  in  the  cord  itself.  Trophic 
action  may  therefore  be  peripheral,  though  in  extensive  changes 
as  a  rule  central  (cerebral  or  spinal)  origin  should  be  looked 
for. 

The  constitutional  result  of  acute  and  chronic  infection  and 
contagions  is  apt  to  be  an  autointoxication  plus  the  action  of 
the  germ  toxin.  All  the  exanthemata  have  at  times  been  fol- 
lowed by  wasting  or  necrosis  of  the  alveolus.  Here  the  con- 
dition is  notably  symmetric  and  accompanied  by  disorders  of 
the  osseous  system  elsewhere.  The  same  is  true  of  grippe  and 
tuberculosis.  The  well-marked  disorder  known  as  Riggs'  dis- 
ease has  been  charged  by  Pierce,  Kirk,  Rhein,  Robin  and  Magi- 
tot  to  the  direct  influence  of  an  arthritic  state  (gouty  and  rheu- 
matic) and  regarded  as  a  special  type  of  arthritic  manifestation. 
The  alveolus  is  clearly  vulnerable  to  the  toxins  of  many  infec- 
tions. It  is  like\\ise  quickly  affected  by  some  autotoxic  influ- 
ences from  disordered  metabolism.  Its  vital  resistance  to  these 
agencies  is  less  than  that  of  other  tissues.  It  is  the  earliest 
sacrifice  when  these  or  any  toxins  disturb  the  harmony  of  the 
organism. 

A  cause  other  than  the  actions  of  toxins  exists  for  impli- 
cation of  these  parts.  Whenever  tissue  waste,  whether  local  or 
general,  exceeds  repair  there  is  trophic  change.  This  latter 
depends  directly  upon  disordered  local  or  general  nervous  func- 
tions. Trophic  alterations  from  the  first  cause  appear  in  growth 
disorders  of  the  nails  and  loss  of  hair  (alopecia)  after  fevers, 
the  most  familiar  obvious  examples  of  this  pathologic  process. 
Of  the  other  type  are  localized  atrophies  where  the  direct  inter- 


CONSTITUTIONAL    CAUSES    OF    INTERSTITIAL    GINGIVITIS. 


205 


vention  of  toxins  can  be  excluded.  The  alveolus  is  liable  to  the 
first  form  of  trophic  deterioration.  The  influence  of  acute  dis- 
eases upon  the  alveolus  is  probably  thus  exerted  in  many  cases 
rather  than  by  direct  infection.  Where  no  cause  has  been  as- 
certained examination  directed  to  this  factor  would  probably 
reveal  it.  The  general  failure  of  the  trophic  centers  after  the 
prime  of  life  (in  senile  states),  which  is  attended  with  loss  of 
teeth  and  wasting  of  the  alveoli,  is  the  most  obvious  instance 
of  trophic  failure  atfecting  the  part.  Even  simple  anaemia  may 
thus  give  rise  to  alveolar  wasting. 

Another   constitutional   disorder   in   which   the   alveolus   is 
early  affected  is  diabetes.     The  exact  pathology  of  this  is  un- 


HH^H 

■i-"-"- 

r 

i 

>-^ 

** 

^ 

'M^^ 

■..■■'' .vfcM  '4. 

Fig.  75. — Absorption  by  Halisteresis.  Three  Small  Arteries  are  Seen.  Two 
IN  the  Upper  Part  of  the  Illustration  with  Eound  Cell  Inflammation  Just 
Beginning,  while  Another  Small  Artery  is  Located  at  the  Lower  Border 
of  the  Large  Absorbed  Area. 


certain,  but  in  many  cases  at  least  it  is  largely  dependent  on 
disordered  action  of  the  central  nerve  system.  Renal  disease 
is  another  common  condition  which  tests  the  vulnerability  of  the 
alveoli.  An  ideally  normal  kidney  is  probably  rare,  but  only 
when  its  abnormalities  pass  beyond  a  certain  point  can  it  be 
called  diseased.  .  In  the  less  advanced  conditions  that  have 
passed  the  line  of  morbidity,  alveolar  implication  is  often  very 


206  INTERSTITIAL    GINGIVITIS. 

marked.  This  may  be  one  cause  of  the  unusual  frequency  in 
the  insane,  who  are  especially  liable  (as  Bondurant  and  others 
have  shown)  to  suffer  from  renal  disease.  They  are  very  liable 
likewise  to  autointoxications  and  trophic  disorders  as  well, 
since  the  balance  of  the  nervous  system  has  been  upset.  Some 
(the  paretic  and  organic  dements)  exhibit  especial  tendencies 
to  trophoneurotic  disturbances  affecting-  the  teeth.  In  states  of 
depression  and  stupor,  circulatory  disturbances  predispose  to 
these. 

The  constitutional  results  of  acute  and  chronic  infections 
are  apt  to  include  autointoxication  in  addition  to  the  action  of 
the  toxins  of  their  germs.  The  eruptive  fevers,  especially 
scarlatina  or  measles,  have  been  long  known  to  be  followed  by 
wasting  or  necrosis  of  the  alveoli.  Here  the  condition  is  notably 
symmetrical  and  unaccompanied  by  exfoliation  or  necrosis  of 
the  osseous  system  elsewhere.  Tuberculosis  does  not  spare 
the  alveolar  process. 

The  more  marked  forms  of  constitutional  disorders  (typhoid 
fever,  pneumonia,  tuberculosis,  syphilis,  inthgestion  and  preg- 
nancy, etc.)  produce  intense  results. 

The  second  form  of  trophic  failure  in  the  alveolus  is  less 
prominent,  since  it  generally  coexists  with  overshadowing  dis- 
turbance elsewhere  which  it  creates  to  a  certain  extent.  Cruvei- 
lier  noticed  its  occurrence  associated  with  simple  paraplegia, 
regarding  it  as  of  nervous  causation.  In  facial  hemiatrophy 
local  wasting  of  the  alveolus  has  appeared  before  the  disorder 
has  involved  the  jaws  generally.  This  is  sometimes  due  to  a 
local  cause,  but  its  occurrence  and  association  with  other  neuro- 
trophic symptoms  are  suggestive. 

We  have  seen  that  the  action  of  the  heart  plays  quite  a  role 
in  the  constitutional  diseases  of  the  body.  Constitutional  dis- 
eases affecting  the  heart  and  diseases  of  the  heart  itself  cause 
excessive  and  diminished  action  of  this  organ.  This  excessive 
and  diminished  action  causes  changes  in  the  flow  of  the  blood 
in  the  peripheral  capillaries.  Those  organs  first  involved  in 
this  change  of  heart  pressure  are  the  end  organs  of  the  body. 
The  alveolar  process,  therefore,  being  the  most  sensitive  end 


CONSTITUTIONAL    CAUSES    OF    INTERSTITIAL    GINGIVITIS, 


207 


organ,  because  of  its  transitory  nature  and  its  bony  substance 
is  one  of  the  first  to  be  involved  in  autointoxication. 

In  intestinal  putrefaction,  hepatic  and  renal  insufficiency  and 
drug  poisoning  as  well  as  in  other  diseases,  the  heart  becomes 
enlarged  and  a  high  blood  pressure  is  developed.  Dilation  of 
the  arteries  occurs,  especially  in  those  of  end  organs,  resulting 
in  arterio-sclerosis,  which  is  present  in  every  case. 


Fig.    76. — Shows   Bone   Absorption   p.y  Halisteresis,  and  Volkman 
Canal  Absorption. 


To  ascertain  the  blood  pressure  in  patients  suffering  with 
interstitial  gingivitis  I  used  Cook's  modification  of  the  Riva 
Rocci  sphygmomanometer,  this  instrument  being  best  adapted 
for  my  convenience  and  exceedingly  simple.  The  armlet  used 
was  sold  with  the  instrument  and  consists  of  a  rubber  bag  4I/2  by 
40  cm.  The  patients  ranged  from  twenty-seven  to  sixty-seven 
years  of  age.  With  this  instrument  the  normal  adult  female 
arterial  blood  pressure  is  115  to  125  mm. ;  adult  male,  125  to 
135  mm. 

In  twenty-six  females  there  were  three  who  ranged  between 
115  mm.  Hg.  and  125  mm.  Hg.  and  therefore  normal.     Three 


208 


interstitljlL  gingivitis. 


ranged  below  115  iiini.  Hg.,  and  twenty  from  133  mm.  Hg.  to 
180  mm.  Hg. 

In  twenty-fonr  males  there  were  eight  who  ranged  between 
125  mm.  Hg.  and  135  mm.  Hg.  and  therefore  normal.  Three 
ranged  below  125  mm.  Hg.,  and  thirteen  from  133  nnn.  Pig.  and 
160  mm.  Hg. 

When  we  consider  that  thirteen  of  these  patients  were  nn- 
der  forty-five  years  of  age,  the  high  blood  pressure  is  remark- 
able. 

I  have  been  unable  to  demonstrate  Avhether  the  interstitial 
gingivitis  is  accelerated  directly  because  of  the  poisons  circulat- 


/io.7. 


Fig. 


'. — Illustrates  Lacunae  or  Osteoclast  Absorption. 


ing  in  the  blood  vessels,  causing  high  blood  pressure  by  their 
action  upon  the  heart,  or  because  of  their  action  upon  the  vaso- 
motor nerve  governing  the  heart  or  blood  vessels,  or  both.  The 
effect  of  the  toxins  and  extra  blood  pressure  is  to  set  up  irrita- 
tion and  inflammation  of  the  outer  surfaces  of  the  Haversian 
canals,  producing  halisteresis  in  the  vessels  of  Von  Ebner,  pro- 
ducing Volkmanns'  perforating  canal  absorption  and  setting  the 
osteoclasts  at  work,  all  producing  absorption  of  the  alveolar 
process. 


CONSTITUTIOXAL    CAUSES    OF    INTERSTITIAL    GIX(;IVITIS. 


209 


The  question  arises,  which  end  organ  is  the  most  susceptible 
and  first  involved  in  autointoxication!  When  a  man  visits 
the  physician  for  treatment  one  of  the  first  questions  asked  is, 
"What  is  your  occupation?"  If  the  man  replies  that  he  is 
working  in  drugs,  metals  or  mines,  the  physician  examines  his 
patient's  gums  to  note  if  his  system  be  saturated  with  poisons. 
If  a  physician  is  treating  a  patient  for  lues,  the  drug  is  adminis- 
tered until  the  "gums  are  touched,"  which  is  the  only  indica- 
tion his  patient  is  under  the  influence.  One  of  the  most  marked 
symptoms  of  scurvy  is  the  inflammatory  condition  of  the  gums 
and  alveolar  process,  which  are  always  taken  into  consideration 
in  diagnosis. 


Fig.  78. — Loaver  Portion'  Showing  Absorption  of  the  Alveolar  Process 
Below  the  Boots  of  the  Teeth. 


Physicians  agree  that  the  arteries  in  sucli  end  organs  as  the 
kidneys,  brain  and  retina  dilate  under  blood  pressure.  The 
arteries  ramifpng  bone  structure,  dilate  only  imperfectly,  if 
at  all.  Arteries  entering  transitory  bone  structures  gradually 
undergo  pathologic  changes.  After  the  individual  has  obtained 
his  growth  these  arteries  certainly  are  more  susceptible  to  toxin, 
poison  and  blood  pressure  than  those  in  the  kidney,  brain 
or  retina.  I  have  demonstrated  these  pathologic  changes  in 
the  alveolar  process  many  times.  The  toxic  products  circulat- 
ing in  the  blood  affect  the  heart  and  cause  a  high  blood  pressure. 


210  INTERSTITIAL    GINGIVITIS. 

High  blood  pressure,  together  with  toxic  products  circulating 
in  the  blood,  set  up  inflammation  in  the  alveolar  process  and 
gingival  border.  In  the  alveolar  process,  tirst,  because  the  ar- 
teries in  the  soft  gum  tissues,  under  high  blood  pressure,  can 
and  do  expand  and  the  tissues  recover  as  soon  as  the  cause  is 
removed,  but  the  arteries  running  tortuously  through  the  bone 
cannot  expand  to  any  appreciable  extent,  and  the  blood  pressure 
and  toxic  products  cause  inflammation  and  absorption  of  bone 
tissue  without  restoration.  Hence  the  term  ''interstitial  gin- 
givitis" (deep-seated  inflammation  in  the  alveolar  process). 
Cardio  vascular,  nervous,  hepatic  and  renal  diseases,  as  re- 
lated to  interstitial  gingi\dtis,  are  therefore  due  to  the  same 
cause.  In  relieving  or  removing  the  cause  of  interstitial  gin- 
givitis the  other  symptoms  and  diseases  are  relieved,  and  vice 
versa. 

Figure  75  illustrates  a  large  area  of  absorption  with  destruc- 
tion of  the  fibrous  tissue  to  a  larger  extent.  Around  the  border 
is  seen  a  small  amount  of  inflamed  fibrous  tissue.  An  artery, 
once  an  Haversian  canal,  is  also  seen.  About  the  large  area 
are  also  seen  three  Haversian  canals  with  the  inflammatory  pro- 
cess just  beginning. 

Figure  76  shows  four  centers  of  absorption  at  Haversian 
canals.  Through  the  picture  may  be  seen  dark  lines  running  in 
all  directions.  These  are  vessels  of  Von  Ebner,  through  which 
Volkmann's  canal  absorption  takes  place.  A  beautiful  illus- 
tration of  this  is  the  canal  running  from  one  large  area  of 
absorption  to  the  other. 

Figure  77  shows  the  third  form  of  bone  absorption — lacunas 
or  osteoclast  absorption.  Here  a  large  area  of  bone  is  destroyed 
by  these  large  cells. 

Figure  78  is  a  low  power,  showing  the  distribution  of  the 
alveolar  process  between  the  roots  of  two  teeth.  Very  little 
of  the  bone  remains.  When  the  trabeculae  or  fibrous  tissue  is 
destroyed  in  large  areas,  and  especially  in  transitory  struc- 
tures, it  is  rarely  restored. 


CHAPTER  XIX. 

CLIMATIC    INFLUENCES    IN    INTERSTITIAL    GINGIVITIS. 

One  of  tlie  simplest  forms  of  constitutional  disturbances 
which  produce  interstitial  gingivitis  is  that  of  climatic  changes. 
The  effect  of  climate  which  includes  heat,  cold,  moisture,  dryness 
is  generally  recognized  by  physicians  as  having  much  to  do  with 
the  action  of  disease  upon  the  system.  To  such  an  extent  has 
this  subject  been  impressed  on  the  profession  that  the  late  Dr. 
N.  S.  Davis  of  Chicago,  many  years  ago  organized  a  separate 
section  in  the  American  Medical  Association  on  Climatology, 
while  every  medical  congress  has  its  section  on  Tropical  Medi- 
cine. If  this  subject  is  of  so  much  importance  in  the  cause  and 
treatment  of  disease,  especially  in  its  influences  upon  the  ex- 
cretory organs,  how  much  more  important  must  it  be  in  relation 
to  interstitial  gingivitis,  since  the  alveolar  process,  being  a 
doubly  transitory  structure  and  an  end  organ,  is  always  the 
first  affected  by  sudden  and  prolonged  changes. 

Experiments  have  shown  that  cold  acts  as  a  stimulant  and 
increases  the  amount  of  carbonic  acid  exhaled,  while  experiments 
made  by  Dfluger  and  Marcet  also  show  that  a  similar  increase 
from  heat  would  produce  the  same  result.  Both  cold  and  heat 
then  to  a  certain  point  act  as  stimulants. 

The  judicious  change  in  climate,  that  is,  moving  in  winter  to 
warmer  climates  and  vice  versa,  taking  into  consideration  mois- 
ture, light,  rarification  or  condensation  of  air  and  the  increase 
by  the  variations  in  the  manner  of  life  and  hygiene  may  prove 
beneficial  or  disastrous  according  as  the  organs  respond  to  the 
changed  environment. 

In  low  temperature,  the  body  loses  more  heat  and  the  loss 
must  be  supplied.  The  older  the  individual  the  more  marked 
is  the  effect  of  excessive  cold  and  heat.  The  effects  upon  the 
individual  are  the  same  as  in  high  temperatures,  in  part  through 
local  injury  and  death  of  tissue,  in  part  through  refrigeration 
of  the  entire  body.     Severe  and  lasting  lowering  of  tempera- 


212  INTERSTITIAL    GINGIVITIS. 

ture  causes  tissue  death;  after  mild  chilling  has  occurred,  as 
the  result  of  tissue  degeneration,  thrombosis,  hyperaemia  and 
exudations  which  are  relatively  rich  in  leucocytes.  A  very  short 
refrigeration  at  the  freezing  point  is  sufficient  to  produce  de- 
generative changes  which  are  quickly  followed  by  regenerative 
proliferation  on  the  part  of  the  cells  remaining  uninjured.  Tips 
of  the  extremities,  nose,  ears,  fingers,  feet  and  toes,  are  the  most 
easily  frozen  because  of  their  extreme  distance  from  the  heart. 

According  to  Ziegier,  '' Besides  the  more  severe  forms  of 
local  or  general  lowering  of  the  tissue  temperature  there  may 
occur,  as  harmful  pathogenic  influences,  mild,  general  or  local 
chillings,  the  so-called  colds,  as  the  result  of  which  disease- 
phenomena  may  manifest  themselves  partly  at  the  seat  of  chill- 
ing, partly  in  organs  in  distant  parts  of  the  body.  For  example, 
after  widespread  refrigeration  of  the  skin  there  may  occur 
diarrhoea,  catarrh  of  the  respiratory  tract,  or  disease  of  the 
kidneys;  after  local  chilling  of  the  skin,  painful  affections  of 
the  deep-seated  muscles.  The  exact  relation  between  these  phe- 
nomena and  the  refrigeration  is  unknown  (the  oft  repeated 
hypothesis  that  they  are  due  to  hyperaemia  of  the  internal  or- 
gans caused  by  the  chilling  of  the  body  surface  has  not  been 
proven),  but  there  is  no  reason  on  this  account  to  deny  the  exis- 
tence of  diseases  caused  by  cold.  Though  many  diseases  for- 
merly attributed  to  "catching  cold"  have  been  known  to  be 
of  infectious  origin,  there  yet  remain  a  number  of  diseased  con- 
ditions for  which  we  know  no  other  etiology  than  that  of 
refrigeration.  Conditions  of  the  body  in  which  the  skin  is  hy- 
peraemic  and  the  perspiratory  function  active  favor  the  taking 
of  cold.  Many  individuals  appear  to  possess  a  predisposition 
on  the  part  of  certain  tissues  to  the  effects  of  refrigeration ;  in 
one  person  certain  muscles,  in  another  the  mucous  membranes 
will  be  affected. 

According  to  the  view  of  many  writers,  refrigeration  of  the 
body  increases  the  susceptibility  to  infection,  so  that,  for  ex- 
ample, the  pathogenic  bacteria  which  may  be  present  in  those 
cavities  of  the  body  accessible  from  without,  may,  after  such 
refrigeration,  be  able  to  exert  their  injurious  influences  upon 
the  tissues." 


CLIMATIC  INFLUENCES  IN  INTERSTITIAL  GINGIVITIS.  213 

There  is  a  great  difference  between  radiated  or  sun  heat  and 
shade  heat.  Sunstroke  is  rare  in  the  pure  and  comparatively 
dry  air  of  high  elevation.  The  same  is  true  on  the  ocean.  Shade 
heat,  on  the  other  hand,  can  be  borne  less  easily.  One  can  do 
hard  work  in  the  sun  heat  when  one  would  rapidly  become  ex- 
hausted in  shade  heat  at  one-third  the  temperature.  People 
bear  heat  very  differently.  The  manner  of  living  must  neces- 
sarily be  taken  into  consideration.  It  has  been  shown  that  Eu- 
ropeans who  go  to  live  in  hot  climates  are  injured  by  continuing 
the  same  kind  and  amount  of  food  and  stimulants  as  they  are 
accustomed  to  use  at  home.  Parkes  says,  ''great  heat  in  shade 
exerts  a  depressing  influence  lessening  the  great  functions  of 
digestion,  respiration,  sanguinification  and  directly  or  indirectly 
the  formation  and  destruction  of  tissue." 

Dr.  G.  D.  Boak  states  as  to  Philippine  climatic  effects  upon 
the  teeth:  "While  the  weather  is  by  no  means  as  hot  as  it  is 
at  times  during  the  summer  in  the  States,  the  average  tempera- 
ture for  the  islands  is  about  89°  F.  It  is  a  continuous  heat  Avith- 
out  invigorating  change  of  seasons.  This  gradually  saps  vital- 
ity and  enervates,  producing  the  lassitude  which  is  characteris- 
tic of  the  tropics.  Enervation  produces  anaemia,  with  corre- 
sponding lessening  of  the  resisting  powers  from  the  lower 
vitality,  especially  in  those  who  have  lived  previously  in  tem- 
perate climates.  Caries  is  frequent  and  progresses  rapidly 
in  this  climate."  This  Dr.  Boak  attributes  to  the  follomng 
causes:  First,  lowering  of  the  vitality  by  a  lessening  of  the 
resisting  powers ;  second,  acidity  of  the  oral  secretions. 

Among  important  factors  to  be  considered  in  connection  with 
hygiene  in  the  tropics  are  the  questions  of  dietetics  as  well  as 
the  effects  of  moist  and  dry  heat.  The  two  last  produce,  as 
elsewhere  shown,  a  neurasthenia  with  co-existing  and  complicat- 
ing autointoxication.  These  two  peculiarly  affect  the  alveolar 
process.  It  is,  therefore,  not  remarkable  to  find  in  a  recent 
report  by  General  Otis,  the  case  of  Walter  Fitzgerald,  Com- 
pany C,  twenty-ninth  infantry,  formerly  of  the  Montana  volun- 
teers, cited.  This  twenty-three-year-old  man  had  been  in  the 
Philixjpines  for  a, year  and  seven  months.  He  was  one  of  the 
first  volunteers  to  reach  Manila  after  the  naval  battle.     Nine- 


214 


INTERSTITIAL    GINGIVITIS. 


teen  months'  life  in  the  tropics  on  the  usual  army  rations  had 
resulted  in  the  loss  of  nearly  every  tooth.  While  the  climate 
undermines  nutrition  of  the  alveolar  process,  and  tropical  fevers 
have  the  same  effect,  improper  diet  increases  the  defect.  In  the 
case  of  Fitzgerald,  the  teeth  dropped  out  one  by  one,  as  is  com- 
monly the  case  with  Americans  in  the  Philippines. 

Soldiers  going  from  a  temperate  climate  to  Cuba  and  the 
Philippines  with  change  of  food,  had  autointoxication  and  in- 
terstitial gingivitis. 

In  an  examination  of  the  soldiers  and  officers  of  two  com- 
panies who  had  just  returned  from  the  Philippines,  located  at 
Fort  Sheridan,  Illinois,  I  obtained  the  following  results:  The 
total  number  examined  was  127.  American,  98;  'Irish,  12; 
German,  9;  English,  3;  Norwegian,  1;  South  American,  1; 
Danish,  1;  Russian,  1;  Cuban,  1.  The  ages  ranged  from  21  to 
52.    By  ages  the  following  data  was  obtained : 


Age 

Disease 

Age 

Disease 

Age 

Disease 

21 

8 

32 

7 

43 

1 

22 

5 

33 

1 

44 

1 

23 

17 

34 

2 

45 

none 

24 

12 

35 

none 

46 

1 

25 

15 

36 

1 

47 

1 

26 

9 

37 

7 

48 

none 

27 

4 

38 

1 

49 

none 

28 

8 

39 

3 

50 

1 

29 

11 

40 

none 

51 

none 

30 

5 

41 

none 

52 

1 

31 

4 

42 

1 

Total:  18  none;  marked  36;  medium  27;  slight  46.  Per- 
centage :    14.1  none ;  28.3  marked ;  21.2  medium ;  36.2  slight. 

In  studying  these  figures  it  will  be  noted  the  largest  number 
of  cases  of  interstitial  gingivitis  occurred  between  the  ages  of 
21  and  30,  the  period  of  life  at  the  constructive  stage  when  the 
disease  should  not  be  present.  Those  over  forty  were  nearly  all 
officers  who  took  better  care  of  the  mouth.  It  must  be  also  noted 
these  men  lived  most  of  the  time  in  the  open  air.  In  the  Amer- 
ican army  mostly  young  men  are  enlisted.  It  will  be  seen  that 
the  effect  of  climate  and  food  is  very  severe.^ 

Even  in  moderate  temperatures  where  changes  of  climate 


The  Dental  Summary,  1903. 


CLIMATIC  INFLUENCES  IN  INTERSTITIAL  GINGIVITIS.  215 

have  taken  place,  strong  persons,  after  long  exposure  to  such 
temperatures,  undergo  a  certain  degree  of  lassitude,  diminution 
of  appetite  and  impairment  of  functions  of  digestion,  respira- 
tion, circulation  and  metabolism.  On  the  other  hand,  it  is  also 
true  that  weak  persons  may  gain  in  weight  and  the  functions  of 
the  mind  and  body  be  much  improved. 

The  sudden  changes  in  temperature  and  atmospheric  pres- 
sure, such  as  mountain  climbing,  balloon  and  aeroplane  ascen- 
sion, may  cause  great  exhaustion,  palpitation  of  the  heart,  ir- 
regular breathing,  unconsciousness,  and  sometimes  vomiting, 
^^ith  bleeding  of  the  gums.  It  is  claimed  by  some  research 
workers  that  the  capillaries  of  the  lungs  are  unable  to  take  up 
sufficient  oxygen  from  the  liighly  rarified  air.  According  to 
the  investigations  of  Schumburg  and  Zumtz  it  appears  that  a 
given  amount  of  labor  calls  for  a  greater  amount  of  oxygen  in 
an  increased  elevation  than  in  a  lower  level.  It  would  seem, 
however,  that  the  sudden  changes  from  moderate  to  extreme 
cold  or  heat  act  upon  the  body  in  such  a  manner  that  the  elim- 
inating organs  are  unable  to  adjust  themselves  quickly  to  the 
new  environment.  The  result  of  this  is  that  autointoxication 
takes  place  and  faulty  metabolism  is  produced. 

During  the  building  of  the  Gornergrat  Eailway  in  Sv\^tzer- 
land,  it  was  found  that  at  a  height  of  three  thousand  meters, 
the  capacity  of  the  laborers  was  diminished  to  one-third.  Ac- 
cording to  the  researches  of  Egger,  Miescher  and  others,  a  so- 
journ in  high  altitudes  leads,  after  a  short  time,  to  an  increase 
in  the  number  of  red  cells  and  a  greater  haemoglobin  content  in 
the  blood. 

Hafner '  of  Zurich  has  recently  shown  that  ''the  engineers 
and  workmen  on  the  Jungfrau  railway,  obliged  to  remain  a  con- 
siderable time  at  altitudes  of  about  2,600  meters  above  the  sea 
level,  are  liable  to  a  disagreeable  complaint.  After  eight  or  ten 
days  they  are  seized  v\dth  violent  pains  in  several  teeth  on  one 
side  of  the  jaw,  the  gums  and  cheek  on  the  same  side  becoming 
swollen.  The  teeth  are  very  sensitive  to  pressure,  so  that  mas- 
tication is   extremely   painful.     These   symptoms   increase  in 


*Die  Natur,  1900. 


216  INTERSTITIAL    GINGIVITIS. 

severity  for  three  days  and  tlien  gradually  and  entirely  dis- 
appear. It  seems  to  be  purely  a  phenomenon  of  acclimatization. 
All  new  comers  pass  through  the  experience  and  the  disorder 
never  recurs."  The  influence  of  heat,  of  cold  and  of  the  baro- 
metric pressure  shown  in  a  lesser  degree  in  "mountain  fever" 
produce  systemic  disturbance  of  metabolism  which,  causing 
autointoxication,  markedly  affect  the  alveolar  process,  producing 
interstitial  gingivitis. 

The  author  has  examined  the  mouths  of  the  workmen  on  the 
Jungfrau,  Gornergrat  and  Pillatus  Railways  at  various  times 
and  can  confirm  the  statements  made  in  regard  to  the  condition 
of  the  men  as  stated  above.  The  quality  of  food,  the  unhygienic 
condition  of  the  mouth  and  high  altitude  have  acted  severely 
upon  the  alveolar  process,  causing  the  teeth  to  loosen  and  drop 
out.  While  the  pathology  is  similar  to  scurvy,  the  other  consti- 
tutional symptoms,  associated  with  scurvy,  are  not  observable 
in  these  patients. 

When  the  Government  authorities  made  their  report  on  the 
survey  of  the  State  of  Minnesota  many  years  ago,  they  made 
the  claim  that  it  was  impossible  for  human  beings  to  live  the 
entire  year  in  that  state  owing  to  the  extreme  cold  in  wdnter. 
It  is  now  known  that  in  the  Northwest,  owing  to  the  extreme  cold 
in  winter,  people  who  live  in  exceedingly  hot  rooms  suffer  from 
the  extremes  of  cold  and  heat  and  are  subject  to  more  severe 
interstitial  gingivitis  than  those  in  more  moderate  temperatures 
in  the  United  States. 

The  results  of  these  extremes  in  temperature  produce  many 
affections  of  the  heart  from  a  want  of  quick  adjustment  of  the 
eliminating  organs  to  the  new  environment.  In  high  altitudes 
and  cold  climates,  the  skin  contracts  and  elimination  of  the  body 
waste  is  thrown  upon  the  internal  organs,  and  vice  versa  in 
warm  climates. 

The  result  is  that  in  these  sudden  extremes,  the  functions  of 
the  body  are  slow  in  adjusting  themselves  to  environment,  nutri- 
tion is  interfered  with,  vitality  is  lowered  and  the  structures  of 
the  body  are  affected  in  the  order  of  their  sensibility  to  auto- 
intoxic  states.  The  peripheral  nerves  are  usually  the  first  in- 
volved; then  the  arterial  coats  and  the  blood  stream  are  inter- 


CLIMATIC  INFLUENCES  IN  INTERSTITIAL  GINGIVITIS,  217 

fered  with.    Transitory  structures  and  end  organs  thus  receive 
the  first  impulses  of  faulty  metabolism. 

This  sets  up  an  inflammation  in  the  capillaries  of  the  alveolar 
process.  No  matter  how  short  a  time  the  cause  may  exist,  if  the 
inflammation  is  once  set  up,  owing  to  its  peculiar  action  on  the 
alveolar  process  (even  though  the  cause  be  removed),  inter- 
stitial gingivitis  becomes  chronic  and  the  destruction  of  tissue 
continues. 


CHAPTER  XX. 

SCURVY  IN  INTERSTITIAL  GINGIVITIS. 

Scurvy  is  due  to  poor  food  and  improper  hygiene.  Insuffi- 
cient alternation  of  food,  impure  air,  want  of  bodily  exercise, 
ennui  and  uncleanliness  combine  to  form  the  causes  of  this  dis- 
ease. Previous  to  the  introduction  of  canned  goods,  sailors  on 
long  voyages,  prisoners  and  others  under  confinement  were 
subject  to  scurvy.  Lunatics,  idiots  or  persons  who  have  had 
long  illness,  and  find  it  difficult  to  regulate  their  diet,  are  now 
most  prone  to  it.  Anaemic  convalescents  from  protracted  fevers 
suffer  from  it.  Bottle-fed  babies  and  occasionally  those  fed  at 
the  breast  on  non-nourishing  milk  are  prone  to  the  disease. 

In  the  British  Arctic  Expedition  of  1875-76  over  forty-eight 
per  cent  of  the  men  suffered  from  scurvy.  When  the  potato  crop 
failed  in  Ireland,  in  1846,  scurvy  became  prevalent.  In  the 
Crimean  war  23,000  cases  occurred  among  the  French  troops 
alone.  Scurvy  contributed  over  fifteen  per  cent  to  the  death  rate 
in  the  late  civil  war.    It  occurs  among  the  Klondyke  miners. 

Thomas  Barlow  found  scurvy  associated  with  rachitis.  Sun- 
derland found  that  rachitic  diathesis  was  a  very  strong  factor. 
Jacobi  reports  forty  cases  of  scurvy  and  rachitis.  Babies  in 
good  families  brought  up  solely  on  the  proprietary  infant  foods 
are  prone  to  scurvy.  They  lose  their  appetites,  become  pallid, 
perspire  freely,  have  diarrhoea,  the  mouth  becomes  sore,  with  in- 
flamed mucous  membrane  and  gums.  Purpura  and  hemorrhages 
of  mucous  membrane  are  common  with  pain  and  swelling  of  the 
joints. 

Just  how  far  scurvy  may  be  associated  with  extreme  changes 
in  climate  in  relation  to  interstitial  gingivitis  is  an  open  question, 
but  soldiers  going  from  one  climate  to  another,  as  exampled  by 
American  soldiers  to  Cuba  and  the  Philippines,  and  British  sol- 
diers to  South  Africa  and  India,  are  more  subject  to  scurvy 


^Brit.  Epidemiological  Society,  Feb.  19,  1904. 


SCURVY  IN  INTERSTITIAL  GINGIVITIS.  219 

from  improper  food  than  native  soldiers.  Mayer  Coplans  ^  of 
tlie  British  Army  Medical  Service  states,  in  regard  to  the  South 
African  War,  that  scurvy  developed  among  the  local  population, 
in  the  concentration  camps,  fed  upon  Government  rations  which 
were  of  fairly  good  quality.  The  concentration  of  native  women 
and  children  in  camps  containing  about  5,000  persons,  forty- 
eight  per  cent  of  children  under  twelve  years  of  age  contracted 
the  disease.  Among  adults  the  women  were  to  the  men  as  three 
to  one.  Enclosed  by  barbed  wire,  the  camps,  though  open  and 
airy,  were  securely  isolated.  The  conditions  being  identical  the 
varying  incidence  of  scurvy  was  remarkable.  Between  March, 
1901,  and  .Tanuary,  1903,  with  no  cases  at  Standerton  or  Volks- 
rust,  there  were  one  hundred  Europeans  and  one  native  attacked. 
Among  the  soldiers  at  Standerton  and  the  22,000  European 
patients  admitted  to  the  hospital  there  was  but  one;  among  the 
natives  in  the  service  of  the  troops  there  were  attacked  32  per 
cent  of  400  muleteers,  22  per  cent  of  those  attached  to  the  Hus- 
sars and  the  Eoyal  Artillery,  87  per  cent  of  the  scavengers  en- 
gaged in  removing  carcasses  of  animals,  17  per  cent  of  the 
porters  and  about  50  per  cent  of  the  muleteers  in  the  employ  of 
the  repatriation  department. 

The  heaviest  incidence  of  scurvy  was  after  the  close  of  the 
war  and  when  all  restriction  on  food  had  been  removed.  In  fact, 
it  had  no  relation  whatever  to  the  food  but  was  almost  every- 
where directly  in  proportion  to  the  neglect  of  cleanliness,  of 
which  the  natives  had  not  the  most  rudimentary  notions,  espe- 
cially as  regards  the  hygiene  of  the  mouth.  Even  the  outbreak 
among  the  burghers  at  Middleburg  followed  overcrowding  and 
neglect  of  sanitation. 

A.  E.  Wright,  in  discussing  the  subject,  said  filthy  habits 
were  not  peculiar  to  the  Kaffirs,  and  were  not  always  accom- 
panied by  scurvy,  which  occurred  in  the  nurseries  of  the  rich  and 
in  nursing  homes.  Scurvy  was  essentially  an  acid  intoxication, 
a  reduction  in  the  alkalinity  of  the  blood  which  can  be  observed 
long  before  the  grosser  manifestations,  alike  in  the  adult  and 
infantile  forms.  A  large  proportion  of  the  troops  returning  from 
South  Africa  were  scorbutic  in  the  latent  stage. 


220  INTEESTITIAL    GINGIVITIS. 

K.  B.  Goadby  also,  in  a  discussion  of  the  subject,  said  he  had 
not  seen  any  scurvy  at  the  Dreadnaught  Hospital,  but  had  met 
much  pyorrhoea  alveolaris,  a  disease  endemic  and  occasionally 
epidemic  in  West  and  Central  Africa,  the  Transkei,  the  Philip- 
pines and  other  places.  This  condition  of  the  gums  and  the  rapid 
recovery  of  the  patients  under  antiseptic  measures  resembled 
that  found  in  scurvy. 

Coplans  pointed  out  in  reply  that  it  required  months  for 
its  development,  for  the  members  of  the  corps  that  suffered 
most  were  recruited  in  their  homes  in  October  and  the  corps  was 
dissolved  in  December,  the  disease  breaking  out  soon  after  their 
arrival  in  the  camp.  Recovery  followed  rapidly  on  purely  local 
treatment  in  the  way  of  buccal  antiseptics  without  any  attempt 
to  influence  the  blood. 

The  term  ''scurvy"  frequently  employed  in  this  discussion  is 
applied  to  the  disease  of  the  mouth,  especially  in  relation  to  the 
gums.  Nothing  is  said  in  regard  to  other  symptoms  of  the  body, 
which  would  be  necessary  in  order  to  make  a  clear  diagnosis  of 
scurvy.    The  logical  inference  is  that  such  were  not  present. 

Polar  expeditions  led  to  the  conclusion  that  a  diet  of  fresh 
or  even  raw  meat,  without  any  food  or  vegetables  whatever, 
and  associated  with  hardship,  dirt  and  misery,  or  one  consisting 
entirely  of  tinned,  preserved  and  sterilized  foods  of  the  highest 
quality  but  with  no  fresh  food,  animal  or  vegetable,  did  not  pro- 
duce symptoms  of  scurvy,  while  scurvy  appeared  when,  along 
with  potatoes,  etc.,  and  daily  doses  of  lime  juice,  the  bulk  of  the 
food  consisted  of  ordinary  salt  beef  or  pork.  Until  the  recent 
Antarctic  expedition,  from  that  of  Xordenskjold  in  the  Vega, 
none  had  been  attacked  by  scurvy  except  that  of  Jackson,  whose 
men  remained  on  board  the  ship  where  they  had  lime  juice,  po- 
tatoes, etc.,  but  refused  the  coarse,  even  "gamey"  bear's  flesh, 
on  which  alone  the  exploring  party  subsisted.  All  were  attacked 
with  scurvy,  two,  indeed,  dying.  The  Laplanders  of  Finland 
bartered  for  farinacea,  etc.,  but  ate  their  fish  putrid  by  prefer- 
ence, and  suffered  much  from  scurvy. 

In  scurvy  there  is  inflammation  and  bleeding  gums;  the 
gums  puff  up,  thicken  and  bleed  easily;  the  teeth  become  loose 
and  sore  upon  mastication ;  a  disagreeable  odor  comes  from  the 


SCURVY  IN  INTERSTITIAL  GINGIVITIS.  221 

mouth;  salivation  or  ptyalism  results  from  irritation  of  the 
teeth,  as  well  as  scorbutic  anaemia;  the  patient  is  languid  or 
tires,  perspires  freely  upon  exertion,  has  shortness  of  breath  and 
palpitation  of  the  heart;  the  face  is  ashy  gray,  becoming  paler 
each  day ;  hemorrhage  takes  place  in  dilTerent  parts  of  the  body, 
especially  beneath  the  skin,  in  the  muscles  and  beneath  the  peri- 
osteum, as  well  as  in  the  joints.  This  often  gives  considerable 
pain  and  sometimes  causes  inflammation,  with  resultant  pus  in- 
fection. Occasionally  hemorrhage  takes  place  in  the  internal 
structures.  The  temperature  varies  and  botli  febrile  apyretic 
states  occur. 

On  the  other  hand,  the  symptoms  observed  in  interstitial  gin- 
givitis are  confined  to  the  gums  and  alveolar  process.  There 
are  no  constitutional  symptoms.  This  disease  was  formerly 
known  as  pyorrhoea  alveolaris  because  the  disease  was  not  recog- 
nized until  pus  was  observed  about  the  teeth.  It  frequently  ex- 
ists for  years  before  pus  is  noticed.  All  the  teeth  may  be  lost 
without  pus. 

From  what  has  been  said,  it  would  seem  rather  difficult  to 
assume  that  these  mouth  conditions  herein  described  were  en- 
tirely due  to  scurvy.  Changes  in  climate  and  environment  must 
be  considered  in  relation  to  the  interstitial  gingivitis  as  well  as 
unhygienic  conditions. 

It  is  common  to  find  scurvy  in  private  and  state  institu- 
tions w^here  many  people  are  confined,  due  to  a  monotony  of  food. 
The  following  scorbutic  case  was  referred  to  me  by  Dr.  George 
W.  Johnson :  A  twenty -five-year-old  American  was  admitted  to 
Cook  County  Hospital  for  the  Insane  December  2,  1892,  suffer- 
ing wdth  melancholia,  attended  by  delusions  of  persecution  and 
suicidal  tendencies  marked  by  refusal  of  food.  June  1,  1896,  he 
again  began  to  refuse  food,  but  took  liquid  diet  on  persuasion. 
June  29,  the  patient  was  transferred  to  the  hospital  because  of 
his  emaciation  and  scorbutic  symptoms  were  discovered.  July 
18,  the  constitutional  and  local  symptoms  of  scurvy  were  well 
marked.  The  teeth  were  covered  with  sordes  and  loosened. 
Under  antiscorbutic  treatment  these  symptoms  had  fully  dis- 
appeared by  August  13.  Through  the  kindness  of  Dr.  Johnson 
I  was  allowed  to  see  this  patient.    I  found  none  of  the  teeth  very 


222  INTERSTITIAL    GINGIVITIS. 

loose,  showing  the  disease  was  superficial.  I  removed  two  teeth 
that  were  decayed  and  the  most  loose.  These  were  prepared 
for  the  microscope  in  the  usual  way.  The  gums  and  peridental 
membrane  were  in  an  active  state  of  inflammation.  Small  blood 
vessels  were  observed  in  different  localities  with  round  cell 
infiltration  extending  into  the  tissue.  The  root  of  the  right 
superior  second  bicuspid,  with  peridental  membrane  attached, 
showed  active  inflammation  about  an  artery  which  had  thick- 
ened, and  an  area  of  tissue  degeneration,  forming  an  abscess. 
The  interstitial  gingivitis  due  to  scurvy,  drug  or  self-poisoning 
lias  tlie  same  pathology. 


CHAPTER  XXT. 

TOXIXS    PRODVCIXG   TROPHIC    CHANGES. 

The  retrograde  disturbances  of  nutrition  lead  to  degeneration 
of  the  affected  tissue.  Tissue  infiltrations  are  due  to  deposits  in 
the  tissues  of  pathologic  substances  which  have  either  been 
formed  "within  the  body  or  introduced  into  it  from  without. 
These  disturbances  of  nutrition  may  affect  the  alveolar  process 
during  its  period  of  development  and  growtli,  l)ut  more  partic- 
ularly in  a  fully  developed  state. 

Poisons  may  be  di\dded  according  to  their  action  into  three 
groups:  First,  those  producing  local  tissue  changes;  second, 
those  acting  injuriously  upon  the  blood;  third,  those  affecting 
chiefly  the  nervous  system  and  the  heart  without  producing 
recognizable  anatomic  lesions.  The  poisons  of  all  these  groups, 
acting  on  the  alveolar  process,  either  by  producing  irritation  of 
the  blood  vessels  or  by  disturbing  nutrition  because  they  are 
stored  in  the  tissue  by  producing  trophic  and  vasomotor  changes 
through  their  action  on  the  nerves,  work  toward  the  ultimate  end 
of  its  destruction. 

All  causes  which  bring  about  stasis  of  blood  in  the  capillaries, 
such  as  inflammation,  pressure,  hemorrhage  or  blocking  the 
venous  outflow  from  the  part,  will  cause  arrest  of  nutrition. 
Again,  if  the  arterial  supply  be  cut  off  from  any  cause,  destruc- 
tion of  the  process  will  take  place.  Arrest  of  circulation  need 
not  be  permanent.  It  suffices  for  its  evil  effect  if  it  persists  for  a 
certain  time.  The  more  highly  specialized  a  tissue,  the  briefer 
its  vitality  when  deprived  of  blood;  thus,  when  the  blood  supply 
is  cut  off,  absorption  of  the  alveolar  process  takes  place  before 
the  circulation  can  be  re-established.  This  is  more  than  likely 
to  take  place  in  the  alveolar  process  since  it  is  a  doubly  transi- 
tory structure  and  an  end  organ. 

Under  the  influence  of  poisons  of  all  kinds,  the  alveolar  proc- 
ess is  liable  to  be  absorbed.  The  result  depends  on  the  condi- 
tion of  the  patient  and  the  severity  of  the  poison.    The  lowering 


224  INTERSTITIAL    GINGIVITIS. 

of  vital  resistance  is  proportional  to  the  depth  of  the  poisoning, 
and  the  weakened  condition  of  the  tissue  invites  microbic  infec- 
tion and  multiplication,  affording  a  suitable  soil  for  invading 
micro-organisms  which  lead  to  the  development  of  pyorrhoea 
alveolaris.  This  is  true  of  the  poisons  entering  the  arteries  of 
the  process  which  cause  an  increased  pressure  of  blood. 

The  toxins  which  leave  an  indelible  stamp  upon  the  alveolar 
process  are  divisible  into  those  belonging  to  the  condiments, 
foods,  beverages,  drugs,  and  those  arising  from  occupation. 
Tobacco,  alcohol,  tea,  coffee,  opium,  cocoa,  cocaine,  as  well  as 
mercury,  lead,  brass,  potassium  iodid,  phosphorus,  sodium 
chloride  and  other  metals. 

With  tobacco,  as  with  alcohol  and  opium,  the  statistic  method 
generally  proves  fallacious  when  applied  to  degenerative  effects. 
The  most  careful  researches  show  that  the  typical  effects  occur 
as  a  rule  after  long  continued  use  of  tobacco,  sometimes  not 
until  twenty  years  or  more.  While  many  smokers  reach  old  age, 
many  fail  to  live  to  old  age  because  they  are  smokers.  The  skin 
is  subject  to  itching  and  reddening;  the  nerves  of  taste  are 
blunted  and  patches  develop  in  the  throat;  loss  of  appetite, 
epigastric  fulness,  pain,  vomiting  and  disturbance  of  bowel  func- 
tion are  common.  Menstrual  disturbance  occurs  in  women,  and 
in  female  cigar-makers  abortion  and  pluriparity  are  frequent. 
The  sexual  appetite  is  impaired,  and  sometimes  sterility  and 
impotence  occur.  Disturbed  heart  action,  palpitation,  rapid  and 
intermittent  pulse,  precordial  anxiety,  weakness,  faintness  and 
collapse,  with  sclerosis  of  the  coronary  arteries  of  the  heart  and 
left  ventricular  hypertrophy  occur  often.  Cigars  and  cigarettes 
produce  irritation  of  the  nose  and  mucous  membrane,  diminished 
smell,  chronic  hyperemia  of  the  epiglottis  and  larynx,  and  some- 
times of  the  trachea  and  bronchi,  predisposing  to  tuberculous 
infection.  Nicotine  amblyopia  is  common,  with  central  disturb- 
ances of  the  field  of  vision  and  slight  color  blindness.  Often 
there  is  disorder  of  the  ear  tubes  and  congestion  of  the  drum, 
with  loss  of  auditory  power  and  consequent  noises  in  the  ear. 
The  central  nervous  system  is  affected.  In  high  schools  non- 
smokers  progress  faster  than  smokers.  Child  smokers,  from 
nine  to  fifteen  years  of  age,  exhibit  less  intelligence  and  more 


TOXINS  PRODUCING  TROPHIC  CHANGES.  225 

laziness  or  other  degenerative  tendencies.  Adults  have  head 
pressure,  sleepiness  or  drowsy  stupor,  depression,  apathy  and 
dizziness.  There  may  also  be  ataxic  symptoms,  paretic  weak- 
ness of  bowels  and  bladder,  trembling  and  spasms.  Tobacco 
insanities,  though  comparatively  rare  in  smokers,  are  common 
in  snuffers  and  still  more  in  chewers.^  In  the  precursory  stage, 
which  lasts  about  three  months,  there  are  general  uneasiness, 
restlessness,  anxiety,  sleeplessness,  and  mental  depression,  often 
of  a  religious  type.  After  this  occurs  precordial  anxiety,  and 
finally  the  psychosis  proper,  consisting  of  three  stages :  1.  Hal- 
lucinations of  all  the  senses,  suicidal  tendencies,  depression,  at- 
tacks of  fright,  with  tendency  to  \iolence  and  insomnia.  2.  Ex- 
hilaration, slight  emotional  exaltation,  with  agreeable  hallucina- 
tions after  from  two  to  four  weeks'  relaxation,  again  followed 
by  excitement.  3.  The  intervals  between  exaltation  and  depres- 
sion diminish,  and  the  patient  becomes  irritable,  but  otherwise 
not  alive  to  his  surroundings.  Perception  and  attention  are  les- 
sened. The  patient  may  be  cured  in  five  or  six  months  if  he  stops 
tobacco  during  the  first  stage.  In  a  year  or  so  he  may  recover 
during  the  second  stage.  After  the  third  stage  he  is  frequently 
incurable.  As  the  patient  becomes  (especially  by  the  use  of  the 
cigarette)  an  habitue  before  puberty,  the  proper  development 
and  balance  of  the  sexual  and  intellectual  system  is  checked. 
These  patients  break  down  mentally  and  physically  between 
fourteen  and  twenty-five.  The  moral  delinquencies,  other  than 
sexual,  are  often  an  especial  tendency  to  forgery  and  deceit  of 
parents.  Frequently  the  insanity  of  puberty  (hebephrenia)  is 
precipitated  by  tobacco.  The  cigarette,  if  used  moderately,  may 
be  a  sedative,  but,  as  used,  is  a  stimulant,  and  is  often  made  of 
spoiled  tobacco,  resembling  in  reaction  morphine,  and  acting  on 
animals  in  a  somewhat  similar  manner.  As  tobacco  turns  the 
salivary  glands  into  excretory  glands,  it  leads  to  imperfect  di- 
gestion of  starch  and  to  consequent  irregular  fermentation  in 
the  bowels,  thus  at  once  furnishing  a  culture  medium  for  mi- 
crobes, from  which  to  form  violent  toxins,  and  likewise  creating 
leucomaines,  to  damage  a  nervous  system  overstimulated  by 


^  Annual  of  the  Universal  Medical  Sciences,  1895. 


226  INTERSTITL\L    GINGIVITIS. 

nicotine.  This  is  one  o:reat  reason  wliy  those  who  use  snuff  and 
chew  tobacco  become  insane  more  frequently  than  smokers, 
albeit  these  last  are  not  exempt. 

Statistics  from  the  female  employes  of  the  Spanish,  French, 
Cuban  and  American  tobacco  factories,  while  defective  and 
somewhat  vitiated  by  the  coexistence  of  other  conditions  pro- 
ducing degeneracy,  support  the  opinion  that  the  maternal  to- 
bacco habit  (whether  intentional  or  the  result  of  an  atmosphere 
consequent  on  occupation)  is  the  cause  of  frequent  miscarriage, 
of  high  infantile  mortality,  of  defective  children,  and  of  infantile 
convulsions.  Tobacco,  therefore,  in  its  influence  on  the  paternal 
and  maternal  organism,  exhausts  the  nervous  system  so  as  to 
produce  an  acquired  transmissible  neurosis. 

Alcohol  has  been  repeatedly  charged  ^ith  being  the  greatest 
factor  in  degeneracy.  The  influence  of  alcohol  on  the  indi\idual 
must  first  be  studied  to  determine  its  potency  and  method  of 
action  as  a  cause  of  race  deterioration.  Careful  medical  re- 
searches have  shown  that  alcohol  produces  a  nervous  state 
closely  resembling  that  induced  by  the  contagions  and  infections, 
and  often  accompani('(l  hy  mental  disturl:)ance.  The  acute  nerv- 
ous state  to  which  the  term  "alcohohsm"  was  apphed  by  Mag- 
nus Huss  has  all  the  essential  characteristics  of  the  nervous 
state  due  to  the  contagions  and  infections  or  mental  exhaustion. 
The  action  of  alcohol  may  be  limited  to  the  central  nervous  sys- 
tem and  thus  produce  hereditary  loss  of  power.  It  may  cause 
changes  or  degeneracies  in  the  peripheral  nerves  which  in  the 
offspring  find  expression  in  spinal  cord  and  brain  disorder 
through  extension  of  the  morbid  process.  But  for  its  deterio- 
rating effects  on  the  ovaries  and  testicles  alcohol  would  be  a 
most  serious  social  danger.  Through  these,  however,  it  tends 
to  prevent  the  survival  of  the  unfit  rather  than  to  develop 
degeneracy. 

Professional  tea-tasters  have  long  been  known  to  suffer  from 
nervous  symptoms.  Very  early  in  the  practice  of  their  occupa- 
tion the  head-pressure  sjmaptoms  of  neurasthenia  appear. 
Tremor  also  occurs  early.  While  changes  in  the  optic  nerve 
have  not  been  demonstrated  beyond  a  doubt,  still  eye  disorders 
have  been  observed  in  the  pauper  tea-drinkers  of  the  United 


TOXINS  PRODUCIXG  TROPHIC   CHAXGES 


90- 


States  and  tlie  tea-ta?tei's  of  Eussia.  iuclicating  similar  changes 
to  tliose  produced  by  tobacco  and  alcohol.  The  tea-cigarette 
habit  has  these  effects.  Bullard  -  finds  that  tea  has  a  ciimulative 
effect.  In  his  experience,  toxic  eft'ects  are  not  produced  by  less 
than  five  cups  daily.  The  symptoms  manifested  are  those  of 
nervous  excitement  resembling  hysteria,  at  times  almost  amount- 
ing to  fury ;  nervous  dyspepsia ;  rapid  irregular  heart  action ; 
heart  neuralgia :  helmet-like  sensation  and  tenderness  along  the 
spine.  James  TVood  "^  of  Brooklyn  found  that  ten  per  cent  of 
those  under  treatment  at  the  city  hospitals  exhibited  similar 
s^miptoms.  Of  these  sixty-nine  per  cent  were  females,  and  every 
symptom  ascribed  by  Bullard  to  tea  was  seen  by  TTood  in  his 
cases,  who  also  found  that  the  women  manifested  irregularities 
in  menstruation  of  a  neurasthenic  or  hysterical  t^1^e.  He  found 
that  these  symptoms  v\-t-re  produced  by  one-half  of  the  quantity 
of  tea  charged  with  these  effects  by  Bullard.  The  Lancet,  sev- 
eral years  ago,  from  an  editorial  analysis  of  the  effects  of  tea- 
tipphng,  took  the  position  that  in  no  small  degree  nervous  symp- 
toms occurring  in  children  during  infancy  were  due  to  the  prac- 
tice of  the  mothers,  both  of  the  working  and  society  class,  in- 
dulging in  the  excessive  use  of  tea,  the  excess  being  judged  by  its 
effects  on  the  individual  and  not  by  the  amount  taken.  Convul- 
sions and  resultant  infantile  paralysis  were  frequently  noticed 
among  the  children  of  these  tea-tipplers.  Obsen'ations  among 
the  factory  population  and  the  workers  in  the  clothing  sweat- 
shops show  that  tea  neurasthenia,  presenting  all  the  ordinary 
symptoms  of  nervous  exhaustion,  is  especially  common.  It  is 
eWdent  that  tea  produces  a  grave  form  of  neurasthenia  readily 
transmissible  to  descendants.  In  addition  to  its  eff'ects  directly 
upon  the  nervous  system,  tea  tends  to  check  both  stomach  and 
bowel  digestion,  and  this  increases  the  self -poisoning  which  is  so 
prominent  a  cause,  consequence  and  aggravation  of  these  nerv- 
ous conditions. 

Coffee  exerts  an  action  very  similar  to  that  of  tea.  although 
the  nervous  s\Taptoms  produced  by  it  are  usually  secondary  to 
the  disturbances  of  the  stomach  and  bowel  diirestiou.     Coffee 


•Annual  of  the  Uni'tersal  Medical  Sciences.  1889. 
^  Ibid. 


228  INTERSTITIAL    GINGIVITIS. 

produces  tremor,  especially  of  tlie  hands,  insomnia,  nervous  dys- 
pepsia and  helmet  sensations.  With  the  exception  of  certain  dis- 
tricts of  the  United  States  coffee  abuse  is  not  carried  to  such  an 
extent  as  tea,  albeit  in  these,  as  in  some  portions  of  Germany,  the 
habit  is  an  excessive  one.  The  conditions  described  result  in 
Germany  as  frequently  as  they  do  in  the  United  States.  Mendel  ^ 
finds  that  in  Germany  coffee  inebriety  is  increasing  and  sup- 
planting alcohol.  Profound  depression,  with  sleeplessness  and 
frequent  cortex  headache,  are  early  symptoms.  Strong  coffee 
will  remove  these  temporarily,  but  it  soon  loses  its  effect  and 
they  recur.  The  heart 's  action  is  rapid  and  irregular,  and  nerv- 
ous dyspepsia  is  frequent.  L.  Bremer  of  St.  Louis  has  observed 
similar  conditions  among  both  Germans  and  Americans  there. 
Opium  seems  to  be  the  Charybdis  on  which  the  human  bark 
strikes  when  escaped  from  the  Scylla  of  alcohol.  Its  abuse  as  a 
narcotic  is  much  older  than  is  generally  suspected  even  among 
the  English-speaking  races.  Murrell  over  ten  years  ago  demon- 
strated that  the  inhabitants  of  the  Lincolnshire  fens  had  long 
employed  opium  as  a  prophylactic  against  malaria.  The  ratio 
of  insanity  in  these  regions  proved  to  be  very  great.  The  same 
conditions  obtained  in  central  malarial  regions  of  New  Jersey 
and  Pennsylvania,  where  the  use  of  strong  infusions  of  the 
poppy  was  common.  The  statistics  of  Rush  ^  as  to  opium-caused 
insanity  in  Pennsylvania  indicate  that  the  percentage  of  Amer- 
ican opium  abuses  at  the  beginning  of  the  nineteenth  century 
was  very  great.  The  drug  differs  in  two  important  aspects  from 
alcohol — it  is  nearer  in  chemical  composition  to  nerve  tissue, 
and  the  tendency  to  its  use  may  be  transmitted  by  the  mother 
directly  to  the  fetus,  since  it  passes  through  the  placenta  very 
often  unaltered.  Opium  is  a  more  dangerous  factor  of  degen- 
eracy than  alcohol,  since  the  opium  habitue  must  be  in  a  contin- 
uous state  of  intoxication  to  carry  on  his  usual  avocation,  while 
abstinence  from  alcohol  is  perfectly  compatible  with  proper 
work  on  the  part  of  the  alcoholist.  The  opium  habit  is  increased 
by  the  propaganda  carried  on  by  the  habitues,  who  justify  their 
position  by  urging  the  use  of  opium  for  an}^  ailment,  however 


♦  Neurologisches  Centralblatt,  1887. 

^  Observations  on  the  Brain  and  Mind.     Page  10,  1798. 


TOXINS  PRODUCING  TROPHIC  CHANGES.  229 

trifling.  Opium,  like  alcohol,  causes  nervous  exhaustion  similar 
to  but  greater  than  that  of  the  contagions  and  infections.  From 
the  affinity  of  opium  to  nerve  tissue ;  from  its  tendency  to  stim- 
ulate the  heart,  thus  causing  increased  blood  supply  to  the  brain ; 
from  its  action  on  the  bowels  and  the  increased  resultant  work 
of  the  liver,  this  nervous  state  is  much  intensified.  Opium  does 
not  interfere  with  the  structure  and  fecundation  of  the  ovary 
and  testicles  like  alcohol,  hence  the  danger  of  the  opium  habitue's 
children  surviving.  Opium,  when  smoked,  stimulates  the  re- 
productive apparatus  and  thus  greatly  increases  the  number  of 
degenerates  due  to  this  habit,  although  the  defects  due  to  the 
inheritance  of  the  habit  and  their  consequences  lessen  survival. 

While  coca  took  its  place  but  recently  among  the  toxic  causes 
of  degeneracy,  it  was  a  factor  of  Peruvian  degeneration  long 
ere  the  discovery  of  America.  Forty- three  years  ago  ^  Euro- 
peans or  people  of  European  origin  in  different  parts  of 
Peru  had  fallen  into  the  coca  abuse.  A  confirmed  chewer 
of  coca,  called  a  cocpiero,  becomes  more  thoroughly  a  slave  to 
the  leaf  than  the  inveterate  drunkard  is  to  alcohol.  Some- 
times the  coquero  is  overtaken  by  an  irresistible  craving 
and  betakes  himself  for  days  together  to  the  woods  and 
there  indulges  unrestrainedly  in  coca.  Young  men  of  the 
best  families  of  Peru  are  considered  incurable  when  addicted 
to  this  extreme  degree,  and  they  abandon  white  society 
and  live  in  the  woods  or  in  Indian  ^dllages.  In  Peru  the  term 
''white  coquero"  is  used  in  the  same  sense  as  irreclaimable 
drunkard.  The  inveterate  coquero  has  an  unsteady  gait,  yellow 
skin,  quivering  lips,  hesitant  speech  and  general  apathy.  The 
drug  has  assumed  an  unusual  prominence  in  the  field  of  degen- 
eracy since  the  discovery  of  its  alkaloid,  cocain. 

In  both  Europe  and  the  English-speaking  countries  the  world 
over  a  habit  has  resulted  which,  while  much  overestimated,  is 
undoubtedly  growing  and  aggravating  as  well  as  producing  de- 
generacy. Many  of  the  cases  reported  as  due  to  cocain  are,  how- 
ever, chargeable  to  the  craving  of  the  hysteric  or  neurasthenic  to 
secure  a  new  sensation,  or  the  desire  on  the  part  of  the  opium  or 


"  Johnson,  Chemistry  of  Common  Life,  Vol.  II. 


230  INTERSTITIAL    GINGIVITIS. 

whisky  fiend  to  try  a  dodge  of  forgiveness  by  friends.  The  habit 
is  very  frequently  induced  by  patent  medicines  taken  to  cure 
catarrh  by  the  neurasthenic  or  to  cure  nervousness  by  the  hys- 
teric as  well.  As  deformities  of  the  nose  passages  predispose  to 
"catarrh,"  patent  medicines  for  local  application  containing 
cocain  are  frequently  employed  in  the  treatment  of  this  supposed 
constitutional  disease,  with  the  result  of  aggravating  the  original 
degeneracy.  The  youth  under  stress  of  puberty  frequently 
ascribes  all  his  ills  to  catarrh,  and  for  it  often  employs  snuffs 
containing  cocain,  and  his  nervous  condition  is  much  aggravated 
thereby.  Among  the  nostrums  urged  in  the  newspapers  and 
magazines  for  this  condition  so  often  resultant  from  nerve  stress 
alone  is  a  snuff  containing  three  per  cent  of  cocain.  From  the 
description  given  by  Johnson  of  the  coquero  there  can  be  no 
doubt  that  tramps,  wandering  lunatics  and  paupers  result  from 
this  habit  to  give  birth  to  degenerates  in  the  next  generation. 

It  is  a  widespread  opinion  among  dentists  that  in  toxic  cases 
the  gums  are  the  first  tissues  involved.  The  fact  is,  however, 
that  when  the  salts  of  mercury  are  taken  into  the  system,  as 
noted  elsewhere,  they  act  directly  upon  the  central  nervous  sys- 
tem; later  occur  nausea  and  vomiting,  tremor  in  the  arms  and 
hands.  Besides  local  nerve  inflammation  (neuritis),  mercurial 
and  brass  poisoning  produce  paralysis  agitans,  and  lead  poison- 
ing, drop  wrist,  etc. 

Excessive  secretions  of  the  glands  of  the  body,  especially  the 
salivary  glands,  later  occur  with  rise  in  temperature,  gingivitis 
with  periosteal  and  peridental  membrane  swelling,  thickening 
of  the  gums  and  loss  of  teeth.  The  central  nerve  system  disturb- 
ance atfects  all  other  structures.  Inflammation  of  the  mucous 
membrane  of  the  mouth,  as  well  as  of  the  gums,  and  of  the  ali- 
mentary canal,  frequently  occurs  with  sloughing  of  tissue.  The 
kidneys  become  involved,  and  are  unable  to  carry  off  the  effete 
matter. 

The  cachexia,  which  resembles  that  of  scurvy,  is  characterized 
by  great  debility,  anemia,  emaciation,  alopecia,  atrophy  and 
coarseness  of  the  nails,  with  pain  in  the  muscles  and  joints. 

Mercury  is  eliminated  by  all  excretory  organs  for  which  it  has 
a  great  affinity.    The  soluble  salts  pass  out  by  the  bowels.    So 


TOXINS  PRODUCING  TROPHIC  CHANGES.  231 

long  as  the  excretory  organs  of  the  body  eliminate  mercury,  the 
tissues  are  not  affected.  Small  doses  are  eliminated,  but  con- 
tinuation of  dosage  soon  involves  the  nervous  system,  and  after- 
wards the  tissues  of  the  body,  especially  the  jaws.  The  first 
effect  of  mercury  upon  dogs  is  to  produce  vivacity  and  anima- 
tion. This  lasts  for  two  or  three  days,  when  the  limbs  begin  to 
tremble.  The  kidneys  and  bowels  act  at  first  freely.  At  the  end 
of  seven  or  eight  days  paralysis  agitans  occurs.  There  is  con- 
stant trembling,  whether  awake  or  asleep ;  loss  of  appetite,  with 
slight  rise  of  temperature.  At  the  end  of  two  weeks  the  gums 
become  inflamed  at  the  margins.  If  the  drug  be  continued,  death 
occurs  in  about  three  weeks.  The  loss  of  flesh  is  remarkable. 
Miners  working  in  mercury  mines,  and  looking-glass  makers,  are 
all  affected  to  a  greater  or  less  extent.  The  nervous  system  is 
always  involved.  The  kidneys  become  diseased.  The  hair  drops 
out.  The  miners  think  it  a  happy  issue  from  their  trouble  when 
they  have  lost  all  their  teeth,  or  even  the  molars.  They  are 
henceforth  exempt  from  suffering  so  far  as  the  teeth  are  con- 
cerned.   Many  are  toothless  at  thirty-five. 

Mercury  taken  by  the  mouth  is  found  in  the  urine  in  two 
hours,  and  in  the  saliva  in  four  hours.  It  appears  in  the  urine 
fourteen  hours  after  it  has  been  applied  to  the  skin.^  Although 
it  is  believed  to  have  passed  entirely  out  of  the  system,  it  has 
been  found  in  the  brain,  liver,  kidneys  and  muscles.  It  is  claimed 
that,  like  lead,  it  forms  combinations  ^dth  albuminoids  in  the 
tissues,  for  a  time  remaining  inert,  to  be  subsequently  oxidized 
and  returned  to  the  circulation  as  an  active  poison.  While  a 
single  dose  of  mercury  may  be  rapidly  eliminated  from  the  sys- 
tem, repeated  small  doses  distributed  over  a  long  period  are  not 
so  eliminated  on  account  of  the  thickness  and  occlusion  of  the 
walls  of  the  capillaries,  producing  endarteritis  obliterans,  hence 
more  or  less  of  it  is  deposited  in  the  tissue. 

Lead  enters  the  system  through  the  alimentary  canal,  skin 
and  respiratory  tract.  A  longer  time  is  required  to  produce 
plumbism  (lead  poisoning)  than  mercurial  poisoning.  Lead  is 
stored  up  in  the  system  in  minutest  quantities  for  an  indefinite 


'  Twentieth  Century  Practice  of  Medicine,  Vol.  Ill,  page  935. 


232  INTERSTITIAL    GINGIVITIS. 

length  of  time.  Its  effects  are  not  manifest  until  the  central  and 
peripheral  nervons  systems  have  become  involved,  as  evinced 
by  the  effect  of  plumbism  upon  the  wrists.  Occasionally,  the 
chief  seat  of  deposit  is  the  liver  or  muscles.  It  is  chiefly  elim- 
inated through  the  kidneys,  and  very  sUghtly  through  the  liver 
and  salivary  glands.  Not  until  a  considerable  length  of  time  has 
elapsed  is  lead  traceable  upon  the  gums.  This  usually  occurs 
about  the  lower  incisors  and  cuspids.  This  deposit  (lead  sul- 
phid)  is  always  in  the  tissue  outside  of  the  blood  vessels.  Plumb- 
ism causes  trembling,  nausea  and  vomiting.  The  patient  loses 
flesh,  becomes  anaemic,  and  has  great  resultant  debility. 

The  lead  circulating  in  the  capillaries  accumulates,  owing  to 
impeded  circulation  resultant  on  the  thickening  of  the  coats  of 
the  vessel,  producing  occlusion.  A  bluish  hue  upon  the  gums 
indicates  that  the  system  is  completely  saturated.  Like  mercury, 
lead  collects  in  the  mucous  membrane  upon  the  inside  of  the 
mouth,  producing  blue  patches  from  a  line  to  one-half  an  inch 
in  length.  Lead  not  only  produces  local  irritation,  but  affects  the 
peripheral  nerves  as  well,  producing  atrophic  changes ;  upon  the 
capillaries  a  thickening  of  the  inner  coat  results  in  endarteritis 
obliterans. 

Lead  produces  in  those  exposed  to  the  fumes  a  systemic  nerv- 
ous exhaustion,  characterized  by  local  paralysis  about  the  wrist, 
as  well  as  the  general  symptoms  of  profound  systemic  nerve 
tire.  This  may  result,  as  was  pointed  out  nearly  half  a  century 
ago,®  in  acute  insanity  of  the  confusional  type  followed  very  often 
by  mental  disorder  of  a  chronic  type  resembling  paretic  de- 
mentia. In  some  cases  the  patient  recovers  from  the  acute 
insanity  to  suffer  thereafter  from  epilepsy.  In  other  cases ""  an 
irritable  suspicional  condition  also  results,  in  which  the  patient 
may  live  for  years,  marry  and  leave  offspring.  This  last  condi- 
tion and  the  epileptic  are  the  most  dangerous  as  to  the  produc- 
tion of  degeneracy.  The  women  employed  in  the  pottery  fac- 
tories in  Germany  suffer,  according  to  Reimert,"  from  a  form 
of  lead-poisoning  which  produces  decidedly  degenerative  effects 


*  Tanquerel  ties  Planches,  Lead  Diseases,  American  Edition,  1848. 

•  Kiernan,  Journal  of  Nervous  and  Mental  Diseases,  1881. 
^°  American  Journal  of  Obstetrics,  Oct.,  1882. 


TOXINS  PRODUCING  TEOPHIC   CHANGES.  233 

upon  the  offspring.    These  women  have  frequent  abortions,  often 
produce  deaf-mutes  and  very  frequently  macrocephalic  children. 

Brass-workers  suffer  from  a  nervous  condition  very  similar 
to  that  produced  by  lead.  Hogden  "  of  Birmingham  and  Moyer  ^- 
have  called  attention  to  the  grave  forms  of  nervous  exhaustion 
produced  among  brass-workers.  The  period  during  which  the 
patient  is  able  to  pursue  the  occupation  without  breaking  down 
is  longer  than  that  of  the  lead-workers.  Women,  like  men,  are 
exposed  to  this  condition.  The  chief  effects  produced,  so  far  as 
the  offspring  have  been  observed,  are  frequent  abortions  and 
infantile  paralysis.    The  green  gum  is  an  early  symptom. 

Potassium  iodide  exerts  a  like  toxic  influence  to  lead  and 
mercury,  as  its  pathology  is  similar  thereto,  but  it  is  of  infre- 
quent occurrence. 

The  employment  of  women  in  match  factories  and  tenement- 
house  sweat-shops  is  growing.  The  chief  toxic  eifect  of  phos- 
phorus is  not  the  localized  jaw  necrosis.  This  is  but  an  e\ddence 
of  the  progressive  system  saturation  with  phosphorus,  and  bears 
the  same  relation  to  the  more  dangerous  effects  of  phosphorus 
that  the  "blue  gum"  does  to  the  systemic  effect  of  lead. 

In  adults,  excess  of  sodium  chloride  in  the  blood  from  con- 
sumption of  salt  meats  and  fish  has  been  noted  with  scurvy^ 
For  this  reason  Eawls,  of  Cincinnati,  Ohio,  believed  that  an 
excess  of  salt  in  the  system  produced  gingivitis.  Languor,  de- 
pression, anaemia,  with  a  rise  of  temperature,  and  enlarged 
joints  with  soreness  are  the  first  symptoms. 

The  effects  of  this  disease  upon  the  system  are  almost  identical 
with  those  of  mercury  and  lead.  Bruise-like  (purpuric)  erup- 
tions occur  upon  the  skin  and  mucous  membrane,  on  the  serous 
membrane  (notably  the  pleura,  pericardium,  meninges  and 
synovial  linings  of  the  joints),  mucous  membrane  of  the  mouth, 
stomach,  intestines  and  bronchi. 

Owing  to  the  anaemia,  vascular  weakness  and  altered  compo- 
sition of  the  blood,  edema  is  common  both  in  the  lungs  and  in  the 
submucous  and  subcutaneous  tissue,  especially  the  feet  and  legs. 
The  o-ums  begin  to  swell  with  redness  and  fibrous  thickening  of 


Birmingham  Medical  Eoview,  Jan.,   1887. 
Medicine,  May,  1904. 


234  INTERSTITIAL    GINGIVITIS. 

the  deep  layer,  which  cause  protrusion,  especially  in  the  cases  of 
degenerates.  The  blood  vessels,  especially  the  capillaries,  be- 
come thickened,  in  some  cases  they  are  occluded,  or  erosion  and 
ulceration  occur.  The  patient  becomes  decidedly  pale  and 
markedly  debilitated.  The  skin  is  dry  and  blanched.  General 
emaciation  is  evident. 

The  mucous  membrane  and  gums  become  swollen  and  bleed, 
stomatitis  ulcerans  results  in  greater  or  lesser  degree.  The 
tongue  is  at  first  swollen,  then  it  becomes  dry  and  hard.  The 
gums  are  at  first  red  and  swollen.  They  bleed  easily  upon  the 
slightest  touch.  Later  they  become  pale  and  are  irregularly 
larger,  somewhat  fungoid  and  friable,  protruding  between  the 
teeth.  They  are  quite  tender  to  the  touch.  Ulcers  appear  on 
the  buccal  surfaces.  The  stomach  becomes  irritable,  nausea  and 
vomiting  are  common.  Constipation  occurs  early  and  diarrhoea 
later  appears. 


CHAPTER  XXII. 

AUTOINTOXICATION  IN  INTERSTITIAL  GINGIVITIS. 

Every  day  we  hear  or  read  of  individuals,  in  the  prime  of 
life  and  to  all  intents  in  good  health,  dying  suddenly.  Post- 
mortem reveals  nothing  whereby  we  may  satisfy  our  minds  as  to 
the  actual  cause  of  death  and  the  case  passes  into  medical  his- 
tory as  an  obscure  condition.  If  we  were  familiar  mtli  auto- 
toxic  states,  I  am  sure  many  of  these  seemingly  obscure  condi- 
tions could  be  accounted  for.  Autointoxication  is  the  rock  upon 
which  the  human  bark  is  wrecked  and  of  which  phj^sicians  know 
so  little. 

The  human  organism  even  in  its  normal  state  is  prone  to  its 
own  destruction  by  poisons.  These  poisons  are  formed  within 
the  organism  itself  or  are  taken  into  it  in  foods,  liquids  and 
drugs. 

Selmi,  the  Italian  toxicologist,  gave  the  name  of  ptomaines 
to  basic  substances  formed  in  putrefying  animal  matter.  From 
their  similarity  to  vegetable  alkaloids,  the  ptomaines  are  often 
spoken  of  as  putrefactive  or  animal  alkaloids.  Leucomaines  are 
animal  alkaloids  formed  by  the  metabolic  processes  of  the 
organism. 

The  processes  of  intestinal  putrefaction  and  the  formation  of 
physiologic  and  pathologic  alkaloids  afford  an  explanation  of  the 
pathogenesis  of  many  diseases,  the  origin  of  which  was  obscure 
until  recent  investigations  gave  us  the  key  by  which  their  true 
nature  may  be  understood. 

We  must  admit  the  great  impetus  given  to  disintegrating 
processes  in  organic  matter  by  bacteria.  In  no  part  of  the  body 
is  this  more  true  than  in  the  alimentary  canal.  During  the  proc- 
ess of  digestion,  changes  of  a  chemic,  putrefactive  and  ferment- 
ing nature  take  place  in  the  small  intestine,  which  give  the  op- 
portunity for  the  formation  of  poisonous  substances,  and  these, 
when  absorbed  have  an  injurious  effect  on  the  system.  There 
is  some  protection  against  this,  however,  if  the  liver,  kidneys, 


236  INTERSTITIAL    GINGIVITIS. 

lungs  and  skin  (the  great  sewers  of  the  body)  be  not  too  deeply 
involved.  When  these  poisons  are  not  eliminated,  or  when  any 
one  of  the  eliminating  organs  becomes  diseased  and  other  organs 
are  obliged  to  perform  that  function,  these  poisons  are  carried 
in  the  blood  stream  to  the  remote  parts  of  the  body.  The  organs 
most  frequently  involved  as  recognized  by  physicians,  are  the 
liver,  kidney,  heart,  brain  and  eye,  but  the  bony  alveolar  proc- 
ess, a  doubly  transitory  structure  and  end  organ  and  the  dental 
pulp,  which  is  the  most  perfect  end  organ  in  tli(^  l)ody,  are  the 
first  to  record  symptoms  of  disease. 

If  the  disease  involves  the  entire  system  and  all  the  elim- 
inating organs,  the  skin,  kidneys,  bowels  and  lungs  are  perform- 
ing, or  can  be  made  to  perform,  their  natural  functions,  many 
of  the  poisons  are  soon  removed.  On  the  other  hand,  if  any  one 
of  these  organs  be  involved,  the  process  of  elimination  is  slower, 
as  the  eliminating  organs,  which  are  not  involved,  must  do  all 
the  work.  At  best  this  is  imperfectly  performed.  A  great  part 
of  these  poisons  is  eliminated  by  the  stools.  Owing  to  the  slow 
movements  of  the  intestinal  contents,  much  of  the  poison  is  ab- 
sorbed by  the  mucous  membrane.  In  faulty  metabolism  or  tissue 
changes,  toxins  are  produced  which  are  absorbed  and  pass  into 
the  lymph  and  blood  vessels.  All  poisons,  producing  intoxica- 
tion, whether  due  to  disease,  tissue  change,  fermentation  or  in- 
fection, are  of  interest  in  their  relation  to  interstitial  gingivitis. 
Many  of  these  auto-infections  are  of  short  duration  and  their 
intensity  is  not  lasting.  On  the  other  hand,  the  toxic  action  of 
mercury,  lead,  brass,  and  of  the  products  of  syphilis,  tubercu- 
losis, scurvy,  etc.,  is  familiar  to  all.  These  poisons  are  of  vital 
importance  to  the  patient  and  physician,  since  they  act  quickly, 
but,  from  the  viewpoint  of  the  stomatologist,  autointoxications 
of  slow  progress  are  the  ones  of  vital  importance.  These  sub- 
stances are  taken  directly  into  the  blood  vessels  and  carried 
throughout  the  system.  This  has  been  repeatedly  proven  by 
Bouchard.^ 

That  man  is  born  free  from  microbes,  was  first  demonstrated 
bv  Metchnikoff.    Soon  after  birth  the  skin  and  mucous  membrane 


Autointoxication  in  Disease. 


AUTOINTOXICATION  IN  INTERSTITIAL  GINGIVITIS.  237 

become  infected,  either  from  the  air  or  water  used  in  bathing  or 
both.  On  an  examination  of  the  intestinal  contents  an  hour  after 
birth,  during  warm  weather,  bacteria  were  found.  Usually  bac- 
teria are  not  described  until  from  twelve  to  twenty  hours  after 
birth.  Micrococci  and  bacilli  flourish  independently  of  food,  for 
they  are  found  in  the  alimentary  canal  before  nourishment  has 
been  taken.  These  microbes  change  in  character  when  mother's 
milk  or  other  foods  are  given  the  child.  The  bacillus  bifidus 
appears  with  mother's  milk.  The  colon  bacillus,  streptococci, 
staphylococci,  lactic  acid  bacillus,  etc.,  with  cow's  milk.  Later, 
with  the  changes  in  diet,  whether  purely  vegetable  or  animal, 
microbic  flora  grow  rapidly  in  the  intestinal  tract.  Vignas  and 
Suckdorf  have  shown  that  an  adult  man  passes  from  30,000,- 
000,000  to  50,000,000,000  of  bacteria  daily  in  the  faeces.  Many, 
perhaps  most  of  these  bacteria,  are  harmless  in  healthy  indi- 
viduals and  the  majority  are  dead.  They  become  exceedingly 
virulent  after  accidents  or  injuries,  such  as  gun  shot,  knife  or 
other  wounds,  strangulated  hernia  and  catarrhal  conditions  of 
the  mucous  membrane.  Man  therefore,  is  in  constant  danger  of 
being  infected.  The  injury  resulting  from  these  micro-organ- 
isms, is  not  from  the  bacteria  themselves  but  from  their  toxins, 
the  products  which  are  absorbed. 

Autointoxication,  without  other  pathologic  states,  is  due  to 
the  absorption  from  the  gastro-intestinal  tract,  of  toxic  material. 
Absorption  is  favored  by  constipation  and  the  toxic  action  is 
enhanced  by  hepatic  insufficiency. 

Before  considering  further  the  putrefactive  changes  within 
the  intestinal  canal,  I  wish  to  speak  here  of  a  subject  about  which 
I  find  little  of  note  by  previous  writers,  namely,  changes  in  the 
digestive  tract,  due  to  evolution.  Evolution  is  based  upon  the 
law  of  economy  of  growth,  laid  down  by  Aristotle,  or  use  and 
disuse  of  structures.  It  is  applicable  here  as  in  other  parts  of 
the  body.  Man,  as  a  whole,  has  undergone  rapid  changes  and 
is  still  undergoing  greater  and  greater  specialization.  In  no 
structure  of  the  human  body  are  these  changes  so  great,  o^ving 
to  disuse  as  in  the  digestive  tract.  When  organs  are  exercised, 
like  the  arms  of  the  blacksmith,  the  hands  of  the  oarsman,  the 
legs  of  the  maiFcarrier,  they  become  enlarged  and  strong.    On 


238  INTERSTITIAL    GINGIVITIS. 

the  other  hand,  when  organs  are  not  used,  like  the  little  muscles 
of  the  ear,  the  small  ribs,  the  little  toes,  the  blood  does  not  flow 
to  the  parts  in  proportion  and  arrest  of  development  results.  I 
have  repeatedly  shown  many  times  the  arrest  of  the  face,  jaws 
and  teeth  in  the  evolution  of  man,  due  to  disuse.  Civilization, 
by  its  custom  of  preparing  food  and  etiquette  in  eating,  has 
caused  rapid  degeneration  of  the  jaws  and  teeth,  resulting  in  ir- 
regularities and  decay.  The  mastication  of  food  is  a  lost  art  with 
many  jDeople,  the  salivary  glands  are  not  excited,  arrest  takes 
place  and  saliva  containing  ptyaline  is  scanty.  Foods  cooked 
and  swallowed  without  mastication  are  taken  into  the  stomach 
with  the  preparation  of  first  digestion.  The  gastro-intestinal 
juices  are  required  to  perform  all  the  work.  Changes  in  the 
liver,  either  as  to  size,  quantity  of  bile  secreted  or  disease  cause 
hepatic  insufficiency.  The  same  is  also  true  of  the  pancreas  and 
gastro-intestinal  juices.  The  size  of  the  stomach,  the  length  and 
deformity  of  the  intestine  and  last,  but  not  least,  the  condition 
of  the  nervous  system  and  the  power  of  the  muscular  coats  of 
the  intestines  to  expel  the  contents  from  the  body  are  to  be 
considered. 

The  evolution  of  the  rectum  and  anus  from  the  placental  and 
oviparous  mammals  is  interesting,  but  is  too  broad  a  subject  to 
be  considered  at  this  time.  This  evolution,  however,  in  its  rela- 
tion to  malformations  and  muscular  tonicity,  owing  to  man's 
upright  position  in  his  phylogeny  must  not  be  lost  sight  of  in  the 
study  of  gastro-intestinal  irregularity. 

The  sedentary  life,  due  to  modes  of  living,  has  brought  about 
many  of  these  changes.  The  digestive  apparatus  has  not  had 
time  to  readjust  itself  to  the  new  environment.  Micro-organisms 
and  pus  germs  which  have  accumulated  in  the  mouth  are  taken 
into  the  stomach  and  intestines  with  every  swallow.  These  may 
produce  injurious  results.  While  the  process  of  digestion  con- 
verts the  protein  or  albuminoid  substances  of  the  food  into  pep- 
tones and  then  into  animo  acids,  the  putrefactive  bacteria  fur- 
ther forms  alkaloidal  and  other  poisons  which  pass  into  the 
blood. 

Direct  demonstration  of  this  fact  has  been  shown  by  many 
investigators.    Planer,  after  ligating  the  colon  found  HgS  in  the 


AUTOINTOXICATION  IN  INTERSTITIAL  GINGIVITIS.  239 

blood  of  the  portal  vein.  Garter  has  found  indican  in  animals, 
the  subjects  of  intestinal  derangements.  Bouchard,  as  well  as 
Planer,  has  observed  alkaloids,  not  only  in  the  tissues,  but  in 
the  blood.  Poisons  formed,  not  only  in  the  intestines,  but  also 
those  existing  in  the  tissues,  are  also  observed  in  the  urine. 

That  an  increase  in  intestinal  putrefaction  will  cause  a  large 
quantity  of  toxic  material  to  pass  through  the  blood  into  the 
urine  has  been  demonstrated  many  times.  Stadeler  in  1848 
found  phenol  in  the  urine.  Bauman  in  1877  found  phenol  in 
fecal  matter.  In  1826,  Tiedeman  and  Gmelin  discovered  a  red 
colored  substance  in  the  duodenum  which  proved  to  be  indol. 
Braconnot  later  found  in  the  urine,  indican  derived  from  indol. 
Prof.  Metchnikoff  of  the  Pasteur  Institute  thinks  old  age  is 
chiefly  caused  by  two  poisons,  phenol  and  indol  which  are  gen- 
erated in  the  intestines  incUiding  such  diseases  as  artero- 
sclerosis,  cirrhosis  of  the  liver,  and  interstitial  nephritis.  He 
might  also  have  mentioned  heart  lesions  and  interstitial  gingi- 
vitis. In  1872,  Jaffe  injected  indol  under  the  skin  and  afterward 
found  indican  in  the  urine.  Later  experiments  by  Senator 
failed  to  find  indol  in  the  meconium  or  indican  in  the  urine  of 
newly  born  infants.  It  is  an  established  fact  today  that  the 
variation  of  indican  in  the  urine  is  governed  by  the  quantity  of 
indol  in  the  faeces.  In  other  words,  the  amount  of  indican  in  the 
urine  depends  upon  the  activity  of  intestinal  putrefaction.  In 
cholera,  typhoid  fever,  intestinal  obstruction,  Hassal,  Gubler, 
Robin,  Carter,  Jaffe  found  large  quantities  of  indican  in  the 
urine.    Senator  showed  indican  in  the  urine  in  constipation. 

Nencki  gave  a  dog  two  grains  of  indol  by  the  mouth,  and  in 
twenty-four  hours  there  appeared  diarrhea.  Twelve  milligrams 
of  a  one  per  cent  solution  administered  subcutaneously  to  frogs 
caused  death.  One  and  five-tenths  to  two  grams  of  indol  ad- 
ministered subcutaneously  to  a  rabbit  in  twenty-four  hours 
proved  fatal.  By  similar  experiments  Salkowsky  found  phenol 
and  cresol  in  the  urine.  Especially  was  this  the  case  in  diarrhea 
and  in  intestinal  obstruction.  There  is  no  doubt  that  in  future 
investigations  other  poisons  will  be  found  in  the  stools  and  urine 
that  produce  marked  poisonous  effect  upon  the  system.  Prod- 
ucts of  putrefacti'on  formed  in  the  intestines,  found  in  the  urine, 


240  INTERSTITIAL    GINGIVITIS. 

must  of  necessity  circulate  in  the  blood  throughout  the  system. 
There  is  a  natural  fermentation  going  on  all  the  time  in  the 
intestines.  In  young  and  middle  aged  people,  when  the  excre- 
tory organs  are  performing  their  office  in  a  healthy  manner,  the 
kidneys,  bowels,  skin  and  lungs  remove  the  poisonous  products 
from  the  body.  When,  however,  putrefactive  products  are 
formed  in  excess,  or  the  excretory  organs  have  lost  their  tonicity, 
has  the  system  other  means  of  preventing  the  accumulation  of 
poisons  in  the  blood?  Certainly,  the  liver  is  intended  to  per- 
form that  office.  This  has  been  proven  by  Schiff.  The  experi- 
ments by  G.  H.  Roger  with  alcoholic  extract  of  rotten  meat 
show  that  when  injected  into  the  portal  vein  it  is  one  half  as 
toxic  as  when  introduced  into  the  circulation. 

Bouchard  has  shown  that  blood  drawn  from  the  portal  vein  of 
a  dog  kills  a  rabbit  in  a  dose  from  thirteen  to  sixteen  cubic  centi- 
meters per  kilogram ;  that  blood  removed  from  the  liver  requires 
twenty-three  centimeters.  He  has  also  shown  that  the  injection 
of  the  extract  of  2.5  grams  of  decomposing  meat  is  sufficient  to 
kill  a  man. 

Many  other  experiments  have  been  made  by  scientists  show- 
ing similar  results.  In  a  summary  of  the  research  work,  it  is 
safe  to  say  that  the  liver  is  intended  to  give  protection  to  the 
system  by  destroying  poisons  especially  those  derived  from  the 
intestines  so  that  the  general  system  does  not  receive  an  amount 
of  these  poisons  above  what  the  excretory  organs  are  able  to 
remove. 

When  all  conditions  work  in  harmony,  that  is,  when  animal 
and  man,  after  years  of  normal  environment,  have  adjusted 
themselves,  disease  is  less  likely  to  result.  When  a  change  of 
environment,  such  as  food,  climate  and  soil,  takes  place,  the 
animal  or  man  becomes  more  susceptible  to  disease.  Thus 
fifty-five  monkeys  died  of  tuberculosis  in  the  Lincoln  Park  Zoo, 
Chicago,  in  one  year,  due  to  change  in  food  and  temperature 
and  to  confinement.  House  dogs  are  more  susceptible  to  dis- 
ease than  street  dogs.  The  Indian  of  North  America  has  been, 
and  is,  dying  rapidly  from  change  in  environment  and  food. 
This  is  true  of  other  primitive   races  throughout  the  world. 


AUTOIXTOXICATION  IX  INTERSTITIAL  GINGIVITIS.  241 

Scandinavians  in  American  cities  are  very  susceptible  to  disease. 
Tlie  same  is  true  of  the  Negro. 

Many  people  are  still  in  the  primitive  stages  as  regards 
their  digestive  apparatus.  They  have  inherited  an  atavistic 
tendency  in  their  large,  well-formed  jaws,  muscles  and  teeth. 
They  masticate  food  and  enjoy  it  like  the  carnivora,  tearing 
and  che^^^.ng  meat  from  a  bone.  The  digestive  apparatus  is 
perfect,  the  bowels,  kidneys,  skin  and  lungs  do  their  work  nor- 
mally, and  they  are  in  perfect  health. 

Many  in  whom  the  digestive  apparatus  is  weak  have  pro- 
gressed along  the  line  of  evolution.  These  people  live  a  seden- 
tary life  one  or  two  generations  in  advance  of  the  tiller  of  the 
soil.  They  are  in  the  transitory  stage,  not  yet  adjusted  to  the 
new  environment.  A  third  class,  born  of  neurotic  parents,  have 
inherited  deformed  internal  organs  the  secretions  and  action  of 
which  are  not  in  harmony  with  each  other.  They  do  not  chew 
their  food  and  digestion  is  impaired.  Their  nervous  systems 
may  be  impaired  from  the  first,  or  may  become  involved  as  a 
result  of  faulty  digestion  and  assimilation. 

Studying  the  three  classes  singly,  it  is  found  that  the  mem- 
bers of  the  first  class  are  healthy,  that  they  can  eat  and  drink 
everything  and  at  all  times,  day  and  night.  They  can  eat  eight 
or  ten  meals  a  day,  like  the  King  of  Portugal,  and  enjoy  them. 
They  can  drink  large  quanities  of  alcohol  or  beer  each  day  with- 
out difficulty.  They  are  rarely  ill.  When  the  senile  stage  be- 
gins, while  there  are  no  marked  symptoms,  the  excretory  organs 
fail  to  perform  their  work  properly.  Interstitial  gingivitis  sets 
in,  the  teeth  loosen,  arteriosclerosis,  kidney  breakdown,  uremic 
poisoning  result  and  at  from  fifty-five  to  sixty-five  death  takes 
place  from  Bright 's  disease,  diabetes,  heart  failure  or  apoplexy, 
the  result  of  excesses. 

The  second  class  easily  produce  acute  gastro-intestinal  fer- 
mentation, autointoxication,  and  are  subject  to  sick  headaches, 
acid  stomachs,  gases  in  both  stomach  and  bowels  and  constipa- 
tion. They  suffer  with  headache,  migraine  and  vertigo,  and 
often  with  nervous  symptoms.  In  these  cases  special  foods  will 
upset  the  entire  system.  Fruits,  raw  as  well  as  cooked,  set  up 
fermentation  in  the  small  intestines  and  putrefaction  results. 


242  INTERSTITIAL    GINGIVITIS. 

Coffee,  chocolate,  cocoa,  beer,  and  the  inhalation  of  tobacco 
smoke  will  distnrb  the  digestion,  produce  cold  extremities,  sick 
headaches  in  a  few  honrs  and  not  infrequently  skin  eruption. 

The  third  class  are  not  only  subject  to  all  the  symptoms  of 
the  first  and  second,  but  frequently  surgical  operations  are  nec- 
essary to  establish  healthy  relations  between  the  digestive 
organs. 

Deformities  of  the  jaws  and  teeth  are  not  uncommon. 
Macaulay  portrays  a  vivid  picture  of  such  a  state  in  Charles  V 
of  Spain.  Among  other  physical  deformities,  he  says,  "At 
length  a  complication  of  maladies  completed  the  ruin  of  all  his 
faculties.  His  stomach  failed,  nor  w^as  this  strange,  for  in  him 
the  malformation  of  the  jaws,  characteristic  of  his  family,  was 
so  serious  that  he  could  not  masticate  his  food,  and  he  was  in 
the  habit  of  swallowing  ollas  and  sweetmeats  in  the  state  in 
which  they  were  set  before  him.  While  suffering  from  indiges- 
tion, he  was  attacked  by  ague.  Every  third  day  his  convulsive 
tremblings,  his  dejection,  his  fits  of  wandering,  seemed  to  indi- 
cate the  approach  of  dissolution." 

Prof.  Eussell  H.  Chittenden  -  in  his  experiments  in  physio- 
logical economy  in  nutrition,  has  shown  that  excess  of  proteids 
means  waste,  "but  of  far  greater  importance  is  the  unnecessary 
strain  placed  upon  the  body  by  this  uncalled-for  excess  of  food 
material  which  must  be  gotten  rid  of  at  the  expense  of  energy 
that  might  better  be  conserved  for  more  useful  purposes." 

He  has  conclusively  shown  that  body  equilibrium  can  be 
maintained  on  half  the  daily  intake  of  food.  The  brain  worker 
and  the  muscle  worker  can  maintain  health,  strength  and  vigor 
on  a  smaller  amount  of  nitrogenous  material  than  is  usually 
consumed ;  "that  an  excess  of  food  is  in  the  long  run  detrimental 
to  health,  weakening  rather  than  strengthening  the  body  and 
defeating  the  very  objects  aimed  at."  This  applies  to  people 
who  have  obtained  their  growth  and  not  to  children. 

Some  neurotics  and  degenerates  are  very  susceptible  to  auto- 
intoxication on  account  of  unstable  nervous  systems.  They 
either  become  easily  constipated  or  toxic  material  accumulates 


'Physiological  Economy  in  Nutrition. 


AUTOINTOXICATION  IX  INTERSTITIAL  GINGIVITIS.  243 

in  the  intestines  and  as  a  result  the  system  becomes  slowly 
poisoned.  Convulsions  occur  in  both  children  and  adults. 
Most,  if  not  all,  insane  patients  are  constipated.  While  it  would 
]iot  be  safe  to  say  that  the  insanity  was  due  to  constipation,  yet 
all  are  greatly  benefited,  and  some  slight  forms  are  cured,  by 
keeping  the  bowels  free  from  microbic  infection. 

Some  of  the  best  specialists  claim  the  skin  eliminates  very 
little  of  the  blood's  poison.  Under  ordinary  circumstances  the 
skin  excretes  water,  salts  in  small  quantities,  carbonic  acid,  and 
in  some  volatile  fatty  acids.  As  age  advances  and  the  elim- 
inating organs  lose  their  activity,  the  bowels  and  kidneys  fail 
to  eliminate  all  the  decomposed  material.  When  these  organs 
become  diseased,  the  skin  and  lungs  assist  in  carrying  off  the 
poisons  or  their  products.  The  skin  especially  is  important  in 
keeping  the  system  in  a  healthy  condition,  free  from  poisons. 

AVhat  the  laity  understand  as  ''spring  fever"  is  but  the  re- 
adjustment of  the  eliminating  organs  from  winter  to  spring. 
People  in  the  senile  stages  feel  better  in  warm  climates  than  in 
cold,  hence  the  custom  of  moving  to  warm  climates  in  winter. 

During  pregnancy,  poisons  are  formed  in  the  mother  and 
fetus  which  circulate  in  the  maternal  and  fetal  blood.  Upon  the 
mother  is  thrown  the  burden  of  eliminating  by  the  kidneys,  liver, 
intestines,  skin  and  lungs  the  bulk  of  the  poison  formed  within 
the  two  organisms.  When  these  poisons  are  retained  auto- 
intoxication is  produced  which  varies  in  degree  from  heighten- 
ing the  arterial  tension,  headache,  gastric  disturbance,  and  lassi- 
tude to  convulsive  seizures  as  in  puerperal  eclampsia.  Intersti- 
tial gingivitis  is  always  present  to  a  more  or  less  marked  degree. 
The  urine  under  these  circumstances  usually  contains  albumin. 
That  errors  of  diet  often  induce  puerperal  eclampsia,  there  is 
no  doubt.  Pregnancy  frequently  advances  normally  until  some 
such  improper  food  as  lobster,  fish,  pork,  pie,  strawberries,  etc., 
is  eaten  ravenously,  when,  as  the  result  of  the  entrance  into  the 
blood  of  imperfectly  digested  products  or  intestinal  poisons, 
eclampsia  follows.  The  presence  of  these  toxins  in  the  blood 
induces  structural  alterations  in  the  renal  epithelia  and  as  a 
consequence  renal  dehris,  tube  casts,  are  present  in  the  urine 
along  with  albumin.    If  the  patient  lives  the  morbid  changes  are, 


244  INTERSTITIAL    GINGIVITIS. 

for  the  most  x^ai't,  temporary,  for  tliey  disappear  on  cessation 
of  the  pregnancy.  We  are  famihar  with  the  dropsical  legs  of 
women  seen  near  the  end  of  pregnancy,  but  it  occasionally  hap- 
pens that  there  is  in  addition  to  the  autointoxication  from  intes- 
tines and  kidneys,  a  hepatic  toxemia,  as  well. 

An  abnormal  degree  of  urinary  acidity  extending  over  a 
period  of  nine  months  accounts  for  many  of  the  neuralgias, 
toothaches,  destruction  of  teeth  by  erosion,  decay  of  the  teeth 
and  wasting  of  the  alveolar  process,  skin  diseases,  and  many 
other  lesions  so  common  in  pregnancy  which  cease  to  trouble 
after  birth  of  the  child.  Mental  strain  due  to  overwork,  grief, 
shock,  etc.,  check  the  secretions,  causing  an  abnormal  degree  of 
urinary  acidity  which  eventually  results  in  diabetes.  Bright 's 
disease  and  arterial  degeneration.  There  are  many  other  lesions 
traceable  to  or  influenced  by  a  high  acidity  of  the  system. 

The  liver  becomes  enlarged  and  tender,  the  patient  slightly 
icteric,  the  stools  pale,  fluid  appears  in  the  abdominal  cavity,  and 
there  are  albumin  and  bile  in  the  urine.  It  is  not  until  the  preg- 
nancy has  been  brought  to  a  natural  or  an  artificial  termination 
that  the  symptoms  and  physical  signs  disappear.  In  such  a  case 
the  liver  has  failed  to  arrest  and  destroy  the  intestinal  poisons 
as  they  pass  through  it  and  the  result  is  that  owing  to  their 
excess  in  the  blood  and  inability  on  the  part  of  the  kidneys  to 
eliminate  them  the  patient  is  poisoned  by  the  products  within 
her  own  body.^ 

One  accustomed  to  the  odor  of  the  skin  and  lungs  and  to  an 
examination  of  the  mouth  in  which  there  is  interstitial  gingivitis, 
can  readily  detect  intestinal  fermentation  and  kidney  irregular- 
ity. Many  times  I  have  detected  a  tendency  to  kidney  lesions 
or  the  lesion  itself,  in  this  manner,  as  was  confirmed  by  subse- 
quent urinalysis. 

Autointoxication  in  disease  is  familiar  to  us  all.  That  the 
l)lood  is  charged  with  effete  matter  or  poison,  due  to  autointox- 
ication, is  abundantly  proven.  Owing  to  a  swollen  mucosa  or 
other  obstruction,  ordinary  nose  breathing  furnishes  an  insuffi- 
cient supply  of  oxygen.    More  air  is  necessary,  hence  the  uncon- 


*  Autointoxication  in  Disease. 


AUTOINTOXICATION  IN  INTERSTITIAL  GINGWITIS.  245 

scions  opening  of  the  month.  A  larger  vohnne  of  air  by  nose 
and  mouth  is  therefore  taken  into  the  hmgs.  Most  people  at  the 
senile  stage  do  this,  most  noticeably,  however,  at  night. 

The  poisonous  products  of  the  intestinal  canal  not  expelled 
from  the  bowels  are  absorbed  and  carried  by  the  portal  system 
to  the  liver.  If  toxic  material  is  sufficiently  modified  by  the  liver, 
it  will  be  carried  back  and  emptied  into  the  bowel  along  A\ith  the 
bile.  If,  owing  to  some  mechanical  obstruction,  as  catarrhal 
swelling,  gall  stones  or  thickening  of  bile,  the  normal  function 
of  the  liver  should  be  interfered  with,  hepatic  insufficiency  re- 
sults. Any  derangement  of  the  bile  or  liver  cells  which  inter- 
feres with  the  proper  function  of  rendering  harmful  substances 
innocuous  would  cause  abnormal  and  poisonous  products  to  be 
carried  in  the  blood. 

The  great  outlet  for  poisons  which  the  liver  fails  to  eliminate 
are  the  emunctories,  chief  of  which  are  the  kidneys.  If  there 
be  too  much  work  in  this  direction,  the  eliminating  function  is 
soon  lost.  The  toxic  material  accumulates  and  results  in  renal 
inflammation  and  albuminuria.  When  this  has  taken  place  the 
blood  becomes  charged  mth  poisons,  the  heart  and  arteries 
undergo  degenerative  changes  with  cardiac  hypertrophy  and 
arteriosclerosis  together  ^yit]l  the  consequent  cardio-vascular 
diseases,  insufficient  blood  supply  to  various  vital  organs,  nerv- 
ous disorders.  Bright 's  disease,  diabetes,  rheumatism,  gout,  uric 
acid  diathesis,  skin  eruptions  and  asthma  result.  Before  these 
diseases  have  become  of  sufficient  importance  to  be  observed  by 
the  physician,  interstitial  gingivitis  has  obtained  full  sway.  In 
all  the  above  mentioned  diseases  interstitial  gingivitis  is  most 
pronounced. 

The  effects  of  autointoxication  on  the  system  are  to  reduce 
its  vitality  or  to  destroy  the  tonicity  of  the  nervous  system,  the 
result  of  which,  end  organs  of  the  body,  the  kidney,  the  brain, 
the  eye,  the  dental  pulp  and  the  alveolar  process  first  become 
diseased.  This  disease  is  brought  about  by  overstrain  upon  the 
peripheral  nerves,  change  in  chemical  structure  of  their  blood 
cells,  irritations  upon  the  coats  of  the  blood  vessels  and  a  gen- 
eral weakening  of  the  part.     The  organ  first  involved  depends 


246  INTEESTITIAL    GINGIVITIS. 

upon  its  anatomy,  its  structure,  its  function,  its  weakness,  local- 
ity, power  of  recuperation,  etc. 

The  poisons  circulating-  in  the  ])lood,  due  to  autointoxication, 
collect  in  the  peripheral  blood  vessels  of  the  alveolar  process, 
change  the  character  of  the  red  blood  cells  and  prevent  nourish- 
ment from  going  to  the  parts. 

A  low  vitality  of  the  structure  is  produced.  Irritation  of  the 
vessel  walls  is  set  up  and  absorjotion  of  the  process  results.  Peo- 
ple in  advanced  years  in  comparative  good  health  (not  ill),  who 
are  attending  to  their  various  affairs  each  day  but  who  do  not 
throw  off  the  poisons  of  the  body  as  readily  as  they  did  formerly, 
have  an  absorption  of  the  alveolar  process  beginning  at  the  gin- 
gival border  and  slowly  extending  toward  the  apical  end  of  the 
root  or  roots  of  the  teeth.  The  severity  of  this  interstitial  gin- 
givitis will  depend  upon  the  vitality  of  the  patient  and  the  degree 
of  poisons  circulating  in  the  blood.  How  much  more  severe, 
therefore,  must  be  the  absorption  when  disease  of  one  or  more 
organs  of  the  body  occurs,  especially  the  eliminating  organs. 

It  has  been  shown  that  poisons  originating  anywhere  in  the 
alimentary  canal  have  been  found  in  the  urine,  that  poisons  en- 
tering the  system  subcutaneously  have  been  found  in  the  urine. 
Some  of  these  poisons  are  modified  in  form  and  intensity  of 
action,  while  others  remain  in  their  original  state.  It  has  been 
a  mooted  question  just  how  these  i^oisons  are  excreted  by  organs 
in  which  they  are  not  formed  but  a  sensible  conclusion  must  be 
that  they  enter  the  blood  and  are  conveyed  by  it  throughout  the 
system  and  partly  eliminated  by  the  kidney. 

In  a  logical  understanding  of  autointoxication  and  its  treat- 
ment an  examination  of  the  urine  should  be  made  in  order  to 
ascertain  the  extent  of  poisons  circulating  in  the  blood. 


CHAPTER  XXIII. 

URIXARY  SIGNS  OF  AUTOINTOXICATION. 

That  changes  in  the  character  of  the  blood  composition  take 
place  from  week  to  week  is  known  to  every  physician.  These 
changes  may  be  due  to  systemic  derangement  or  to  the  character 
of  the  food,  and  are  often  so  great  as  to  affect  the  character  of 
the  tissues  of  the  body,  especially  the  alveolar  process.  We 
have  at  present  no  definite  method  of  testing,  from  time  to  time, 
the  chemical  constituents  of  the  blood.  The  best  and  only  method 
of  obtaining  an  approximate  knowledge  is  by  an  examination  of 
the  urine.  For  many  years  I  have  made  a  special  study  of  the 
constitutional  condition. 

The  examination  of  the  urine  is  the  only  means  at  hand  of 
ascertaining  the  general  condition  of  the  system  underlying 
Interstitial  gingivitis.  Two  factors  are  of  considerable  moment, 
namely,  an  excess  or  diminished  urinary  acidity  and  indican.  I 
^dsh  to  report  three  hundred  and  ninety-four  examinations. 
The  patients  are  from  twenty-seven  to  sixty-seven  years  of  age. 
All  had  interstitial  gingivitis  in  its  most  aggravated  form  with 
loose  teeth  in  varying  numbers.  Thirty-two  had  lost  teeth  as  a 
result  of  the  disease.  Fourteen  had  pyorrhoea  alveolaris  that 
could  be  observed  by  the  naked  eye.  Twenty-four  hours '  urine 
was  obtained.  A  part  or  all  was  sent  to  the  Columbus  Medical 
Laboratory  for  examination.  In  tabulating  the  reports,  the  fol- 
lowing results  were  obtained :  Specific  gravity  taken  in  the  first 
fifty  only,  showed  two  had  1,005;  two,  1,006;  two,  1,008;  two, 
1,009;  one,  1,010;  one,  1,011;  one,  1,012;  two,  1,013;  six,  1,014; 
one,  1,015;  five,  1,016;  two,  1,017;  one,  1,018;  five,  1,020;  three, 
1,023;  one,  1,024;  three,  1,025;  one,  1,026;  two,  1,027;  one,  1,028; 
two,  1,029 ;  one,  1,031.  There  were  granular  casts  in  six  reports ; 
hyaline  casts  in  twelve ;  cylindroid  in  twenty-two. 

The  degree  of  acidity  was  obtained  by  taking  10  c.c.  of  urine 
specimen,  measured  in  the  graduate  glass,  then  placed  in  the 
small  glass ;  four  drops  of  phenolphtalein  were  added;  then  drop 
by  drop  NaOH  (1-10  normal  sodium  hydrate)  until  a  slight  pink- 


248  INTERSTITIAL    GINGIVITIS. 

ish  color  was  produced.  Having:  noted  on  paper  the  niimljer  of 
c.c.  of  the  NaOH  in  the  burette  before  and  after  the  pink  color 
was  obtained,  the  number  of  c.c.  displaced  multiplied  by  10  (in 
order  to  find  the  number  of  c.c.  NaOH  necessary  to  neutralize 
100  c.c.  urine)  equaled  the  degree  of  acidity.  Each  step  in  this 
operation  must  be  carefully  performed,  each  instrument  must 
be  kept  perfectly  clean  in  order  to  get  good  results. 

The  results  showed  two  had  4  degrees ;  two,  6 ;  one,  7 ;  two,  8 ; 
nine,  10;  three,  11;  seven,  12;  one,  13;  eighteen,  14;  five,  15; 
twenty,  16 ;  five,  17 ;  two,  17.5 ;  fifteen,  18 ;  twenty-seven,  20 ;  four, 
21 ;  thirteen,  22 ;  six,  23 ;  fourteen,  24 ;  seven,  25 ;  fifteen,  26 ;  one, 
27;  seventeen,  28;  one,  29;  thirty,  30;  two,  31;  nineteen,  32;  six- 
teen, 34 ;  six,  35 ;  twenty-seven,  36 ;  five,  37 ;  eleven,  38 ;  two,  39 ; 
twenty-two,  40;  two,  41;  eight,  42;  nine,  44;  two,  45;  ten,  46; 
two,  47 ;  seven,  48 ;  one,  49 ;  eight,  50 ;  one,  51 ;  six,  52 ;  two,  53 ; 
one,  54 ;  one,  55 ;  fifteen,  56 ;  one,  57 ;  five,  58 ;  two,  59 ;  seven,  60 ; 
six,  62 ;  three,  63 ;  four,  64 ;  three,  66 ;  two,  68 ;  four,  70 ;  three,  72  ; 
two,  74;  five,  75;  one,  76;  one,  78;  one,  79;  one,  80;  one,  83;  one, 
84;  two,  100;  three,  104;  one,  105;  one,  108;  one,  110;  one,  113; 
one,  120 ;  three,  alkaline ;  two,  neutral.  The  urea  showed  two  had 
.3  per  cent;  one,  .5;  two,  .6;  two,  .7;  two,  .9;  two,  1;  one,  1.1; 
two,  1.3;  one,  1.4;  four,  1.5;  six,  1.6;  one,  1.7;  three,  1.8;  one,  1.9; 
one,  2;  three,  2.1;  three,  2.2;  two,  2.4;  six,  2.5;  two,  2.6;  one,  3; 
one,  3.1 ;  one,  7.1.  Albumin  was  found  in  four  cases ;  blood  in 
six ;  leucocytes  in  forty-five ;  epithelial  cells  in  forty-six ;  uric  acid 
crystals  in  two ;  urates  in  five ;  oxalates  in  fifteen.  Of  the  three 
hundred  and  ninety-four  examinations,  three  hundred  and 
twenty  showed  indican  to  a  greater  or  lesser  extent.  Seventy- 
four  were  normal  in  this  respect. 

To  make  a  more  complete  study  of  each  individual  case,  the 
following  table  has  been  prepared : 

Specific  Casts.  Acid-  Urea- 
Gravity.        Granular.  Hyaline.  Cyhndroid.         Degree.  Percent. 
23  0  0                   0                       60  2.5 
20  1  1                   1                       56  2.5 
8  0  0                   1                      20  1. 
6  0  11                      12  .6 
12  0  0                  0                      36  1.5 
31  0  0                  0                     44  2.6 
29  1  11                      46  2.2 


UEINARY   SIGNS   OF   AUTOINTOXICATION. 


249 


Specific 

Casts. 

Acid- 

Urea- 

Gravity. 

Granul 

ar.  Hyaline. 

Cylindroid 

[.         D. 

egree. 

Per  cent, 

16 

1 

1 

1 

52 

2.2 

11 

0 

0 

1 

17.5 

1.4 

17 

0 

0 

0 

17.5 

1.6 

27 

0 

1 

1 

62 

2.1 

20 

0 

0 

1 

24 

2.2 

25 

0 

1 

0 

44 

2.4 

9 

0 

0 

1 

16 

1.5 

25 

1 

1 

1 

40 

3.1 

29 

1 

1 

0 

58 

2.6 

1-1 

0 

0 

0 

36 

2. 

16 

0 

0 

0 

30 

1.8 

14 

0 

0 

0 

30 

1.5 

13 

0 

0 

0 

36 

1.6 

13 

0 

0 

0 

36 

1.6 

15 

0 

0 

0 

36 

1.7 

15 

0 

0 

1 

15 

1.6 

14 

0 

0 

0 

36 

.9 

28 

0 

0 

0 

36 

3. 

5 

0 

0 

0 

degree 

not  taken 

.3 

16 

0 

0 

0 

( ( 

1.6 

20 

0 

0 

0 

<  i 

1.5 

10 

0 

0 

0 

i  I 

1.1 

25 

0 

0 

1 

i  i 

2.5 

27 

0 

1 

1 

62 

2.1 

25 

0 

0 

0 

degree 

not  taken 

2.5 

14 

0 

0 

1 

30 

1.3 

20 

0 

0 

0 

degree 

not  talven 

1.9 

24 

0 

0 

1 

'< 

2.4 

26 

0 

0 

0 

<  i 

2.1 

18 

0 

1 

1 

ii 

1.6 

14 

0 

0 

1 

30 

1.8 

5 

0 

0 

0 

15 

.7 

23 

0 

0 

1 

40 

1.8 

7 

0 

0 

0 

14 

1.3 

16 

0 

0 

0 

30 

1.8 

9 

0 

0 

1 

11 

.9 

14 

0 

0 

1 

22 

1.5 

7 

0 

0 

0 

20 

.7 

7 

0 

0 

0 

20 

7.1 

23 

0 

0 

0 

60 

2.5 

20 

1 

1 

1 

56 

2.5 

8 

0 

0 

0 

20 

1.0 

6 

0 

1 

] 

12 

.6 

TOTAL  EXAMINATION   OF  URINE. 

Qualitative  Examination. 


Physical  condition : 
Clear 


17 


Present    30 

Absent 29 


Cloudy   .' 33      Albumin : 


250  INTERSTITIAL   GINGIVITIS. 

Reaction :  Present,  trace   4 

Acid 46  Absent 46 

Alkaline 4     Peptones    None 

Color :  Sugar   None 

Yellow 46      Bile  None 

Amber   4  Blood : 

Odor :  Present    6 

Negative   46  Absent    44 

Present 4  Indicaii    50 

^lucin : 

Microscopical  Examination. 

Casts :  Pns 11 

Hyaline   14  Epitbelial    cells 40 

Granular 7  Crystals : 

Epithelial 1  Uric  acid 2 

Cylindroids  21  Urates    5 

Cells :  Oxalates 15 

Blood 4  Phosphates : 

Leucocytes    45  Calcium 1 

The  relation  of  acid  autointoxication  and  montli  acidity  is 
very  intimate.  The  acids  taken  into  the  body  and  those  pro- 
duced by  chemical  changes  within,  such  as  hydrochloric,  lactic, 
acetic,  diacetic,  oxybutyric,  uric,  and  other  acids  circulate  in  the 
system  in  the  form  of  salts  so  that  the  blood  maintains  at  all 
times  essentially  a  neutral  reaction.  If  the  acid  ions  in  the  blood 
at  any  time  overbalance  the  metallic  ions  so  that  there  is  a  con- 
siderable number  of  H  ions  present,  an  excretion  of  acid  takes 
place  and  passes  out  through  the  kidneys,  lungs,  skin,  and 
mucous  membrane,  especially  of  the  mouth.  If  the  kidneys  do  not 
carry  off  the  surplus  acidity,  a  greater  strain  is  put  upon  the 
lungs,  skin  and  mucous  membranes  of  the  mouth.  The  alveolar 
process  and  gums,  being  doubly  transitory,  as  well  as  end  organs, 
contain  excretive  and  secretive  glands.  The  gums  are  the  first 
structure  of  the  body  which  indicate  systemic  defects  partic- 
ularly noticeable  in  mercurial,  lead,  and  brass  poisoning,  scurvy, 
etc.  The  mucous  glands  normally  excrete  acid  fluid,  while  the 
salivary  glands  secrete  alkaline  fluid.  It  not  rarely  happens, 
however,  that  the  kidneys  fail  in  their  function  and  the  system 
becomes  so  saturated  ^\T.tli  acid  that  the  salivary  glands  continue 
to  cause  destruction  of  the  teeth. 

Friction  of  the  lips,  teeth,  and  foreign  bodies  assist  greatly  in 
tooth  destruction.    Teeth  softened  by  faulty  nutrition  and  acid 


UEINARY    SIGNS    OF    AUTOINTOXICATION.  251 

states  are  easily  destroyed  by  acids  and  friction. 

In  an  examination  of  the  urine  of  diabetics,  tabetics  and 
paretic  dements,  I  have  the  following  statistics : 

1.  Urinalysis  of  Diabetic  Patients. — Urinalysis  by  the  Co- 
lumbian Medical  Laboratories  of  three  hundred  and  ninety-four 
diabetics  showed  specific  gravity,  one  1.003,  one  1.005,  one  1.007, 
one  1.010,  one  1.011,  eight  1.012,  one  1.013,  six  1.014,  six  1.015, 
four  1.016,  five  1.017,  seven  1.018,  six  1.019,  seven  1.020,  five 
1.021,  thirteen  1.022,  fifteen  1.023,  ten  1.024,  twenty  1.025,  thir- 
teen 1.026,  thirteen  1.027,  eighteen  1.028,  nineteen  1.029,  twenty- 
five  1.030,  twelve  1.031,  fifteen  1.032,  twenty-eight  1.033,  sixteen 
1.034,  twenty  1.035,  seventeen  1.036,  eighteen  1.037,  nine  1.038, 
twelve  1.039,  ten  1.040,  eight  1.041,  eight  1.042,  two  1.043,  seven 
1.044,  two  1.045,  two  1.046. 

Percentage  of  Sugar. — Twelve  had  0.1  per  cent,  eighteen  0.2, 
three  0.3,  eleven  0.4,  seven  0.5,  seven  0.6,  one  0.7,  four  0.8,  eight 
0.9,  ten  1,  one  1.1,  eight  1.2,  seventeen  1.3,  six  1.4,  one  1.5,  thir- 
teen 1.6,  seven  1.7,  four  1.8,  one  1.9,  five  2,  three  2.1,  six  2.2, 
three  2.3,  seven  2.4,  three  2.5,  five  2.6,  one  2.7,  three  2.8,  three 
2.9,  four  3,  one  3.1,  five  3.2,  six  3.3,  one  3.4,  two  3.5,  ten  3.6,  five 
3.7,  five  3.8,  fifteen  4,  four  4.1,  five  4.2,  two  4.3,  two  4.4,  three  4.5, 
eight  4.6,  four  4.7,  five  4.8,  five  4.9,  five  5,  two  5.2,  ten  5.3,  five  5.4, 
one  5.5,  nine  5.6,  seven  5.7,  five  5.8,  one  5.9,  nine  6,  five  6.1,  ten 
6.2,  ten  6.4,  one  6.5,  five  6.6,  one  6.7,  three  6.8,  five  6.9,  three  7, 
one  7.1,  two  7.2,  two  7.3,  two  7.4,  one  7.6,  one  7.7,  three  7.8,  one 
7.9,  one  8,  one  8.2,  one  8.5,  one  8.7,  one  9,  one  9.1. 

Degree  of  Acidity. — Two  passed  4  degrees,  two  6,  one  7,  two 
8,  six  10,  five  12,  sixteen  14,  one  15,  fifteen  16,  one  17,  thirteen 
18,  twenty  20,  one  21,  twelve  22,  one  23,  ten  24,  two  25,  fourteen 
26,  sixteen  28,  one  29,  twenty-one  30,  seventeen  32,  thirteen  34, 
four  35,  twenty  36,  two  37,  eleven  38,  two  39,  thirteen  40,  one  41, 
eight  42,  seven  44,  two  45,  eight  46,  two  47,  five  48,  five  50,  five  52, 
one  54,  twelve  56,  one  57,  four  58,  five  60,  one  62,  one  63,  three 
64,  two  QQ,  two  68,  two  70,  three  72,  one  74,  one  75,  one  100,  two 
104,  one  120,  one  alkaline,  two  neutral. 

Acetone. — Of  this  number  of  cases  only  nineteen  were  exam- 
ined for  acetone.  In  eleven,  acetone  was  present,  in  eight  absent. 
Thirty-two  were  examined  for  diacetic  acid ;  in  six  it  was  pres- 


252  INTERSTITIAL    GINGIVITIS. 

ent  and  in  twenty-six  absent.     Twenty-four  were  examined  for 
oxybutyric ;  in  all  it  was  negative. 

2.  Urinalysis  of  Tabetic  Patients. — Degree  of  acidity  in 
thirty-five  was  as  follows:  One  passed  5  degrees,  one  6,  one  7, 
three  9,  two  10,  one  11,  one  14,  one  17,  two  19,  two  20,  one  22,  one 
46,  one  48,  one  49,  one  50,  one  56,  one  62,  one  73,  two  76,  one  78, 
one  81,  one  82,  one  84,  one  97,  one  99,  one  112,  four  alkaline. 
Those  patients  having  the  alkaline  urine  had  marked  erosion  of 
the  teeth  showing  that  at  some  time  there  had  been  a  high  degree 
of  acidity.  Cystitis  caused  the  urine  to  become  alkaline.  All 
showed  indican  to  a  greater  or  less  extent. 

3.  Urinalysis  of  Paretic  Patients. — Degree  of  acidity: 
There  were  twenty-one  males,  four  females.  Three  passed  5 
degrees,  one  7,  three  8,  two  9,  one  10,  one  11,  one  12,  one  13,  one 
15,  two  16,  one  17,  one  22,  one  28,  one  34,  one  38,  one  39,  one  44, 
one  51,  one  52,  one  70.  These  patients  were  in  a  quiet  state.  If 
the  urine  could  have  been  examined  after  excitement  or  an  ex- 
plosion the  degree  of  acidity  would  have  been  greater. 

4.  Urinalysis  of  Private  Patients. — Degree  of  acidity:  I 
examined  one  hundred  and  twenty-nine.  Three  were  also  sent  to 
me  by  Dr.  J.  F.  Keefe  of  Chicago,  making  in  all  one  hundred  and 
thirty-two.  They  were  from  eleven  to  eighty-four  years  of  age. 
All  showed  erosion  and  abrasion  to  a  greater  or  less  extent. 
Three  passed  2  degrees,  three  8,  two  10,  two  11,  seven  12,  two 
14,  two  15,  five  16,  six  18,  two  19,  eight  20,  five  22,  five  24,  six  26, 
four  28,  two  29,  six  30,  two  31,  four  32,  two  33,  three  34,  nine  36, 
two  38,  two  40,  two  44,  five  46,  one  47,  two  48,  two  50,  five  52 ;  five 
54,  four  56,  one  58,  three  60,  two  62,  five  70,  one  90,  one  127,  one 
132,  only  four  or  3.8  per  cent  had  uric  acid.  I  quote  here  from  a 
previous  paper,  '' Interstitial  Gingivitis  Due  to  Autointoxica- 
tion," my  first  fifty  patients'  degree  of  acidity,  one  had  11  de- 
grees, two  12,  one  14,  two  15,  one  16,  two  17.5,  four  20,  one  22,  one 
24,  five  30,  seven  36,  two  40,  two  44,  one  46,  two  56,  one  58,  one  59, 
one  60,  two  62 ;  3  per  cent  had  uric  acid,  all  had  indican. 

The  acidity  of  a  single  specimen  of  urine  will  vary  like  the 
specific  gravity  within  large  units,  corresponding  to  the  amounts 
of  acid  entering  the  blood  from  various  sources.  The  normal 
degree  of  acidity  of  the  urine  is  from  30  to  40  degrees.    A  low 


URINAEY  SIGNS   OF   AUTOINTOXICATION.  253 

acidity  may  arise  from  several  factors :  1.  A  large  excretion  of 
water,  as  in  nervous  states,  diabetes  insipidus,  etc.  2.  A  diet  con- 
taining a  large  quantity  of  salts  of  the  vegetable  acids.  3.  A  cor- 
responding deficiency  of  meat  which  yields  acid  salts.  4.  A  defi- 
cient power  of  the  kidney  to  excrete  acid.  5.  Excessive  elimina- 
tion of  acid  by  other  emunctories.  In  patients  in  whom  the 
degree  of  acidity  exceeds  40%  there  is  excessively  imperfect  oxi- 
dation which,  irrespective  of  the  types  of  acid,  underlies,  as  is 
now  pretty  generally  recognized,  severe  constitutional  stress 
allied  to  that  of  diabetic  acidosis. 

The  quantity  of  urine  passed  in  twenty-four  hours  influences 
the  degree  of  acidity.  Thus,  if  more  than  40  ounces  (about  the 
normal  amount)  be  passed,  the  degree  of  acidity  with  the  same 
total  amount  of  acid  would  be  low  as  compared  with  less  than 
40  ounces. 

On  application  of  the  phenolphtalein,  if  the  urine  specimen 
turns  pink,  it  is  alkaline,  therefore  no  degree  of  acidity  can  be 
obtained.  Litmus  paper  is  applied  to  the  gums  and  lips  to  ascer- 
tain if  the  mucus  be  acid.  Acid  mucus  was  found  in  every  case 
tested.    The  circle  of  evidence,  therefore,  is  complete. 

Few  adult  persons  have  not  had  an  excess  of  acidity  at  some 
period.  Complete  oxidation  is  essential  to  a  normal  condition. 
The  organs  and  tissues  of  the  body  act  as  best  they  can  to  bring 
about  this  condition.  In  some  systems,  the  liver  has  all  it  can  do 
to  care  for  the  waste  products  of  the  tissues  themselves.  That 
the  salts  of  fruit  acids  may  be  converted  into  alkaline  substances 
in  the  system  is  true.  The  liver  and  tissues  become  overworked. 
The  fruit  habit  (especially  grape  fruit)  so  generally  indulged  in 
to  excess  in  America  is  producing  havoc  with  the  alveolar  proc- 
ess, gums  and  teeth. 

One  case  is  sufficient  illustration  of  the  many  requiring  treat- 
ment. A  twenty-seven-year-old  woman  had  her  teeth  and  mouth 
put  in  good  condition  in  January,  1907.  February  16  she  re- 
turned \\dth  what  she  thought  a  cavity  at  the  cervical  margin  of 
the  left  superior  cuspid.  Upon  examination,  I  found  the  gums 
inflamed  and  receding,  not  only  at  that  particular  location  but 
about  all  the  teeth.  Previous  to  this,  the  gums  and  mucous  mem- 
brane were  in  fairly  good  condition.     Litmus  test  showed  the 


254  INTERSTITIAL    GINGIVITIS. 

mucus  to  be  very  acid.  There  was  no  cavity,  only  sensitive  ex- 
posed dentine.  Much  gas  was  passing  from  the  stomach.  Upon 
interrogation  in  regard  to  her  food  she  informed  me  she  had 
been  eating  grape  fruit  every  morning  for  three  weeks.  Urin- 
alysis of  a  twenty-four-hour  specimen  showed  the  degree  of 
acidity  to  be  fourteen.  Sixteen  degrees  were  retained  in  the 
system.  The  recession  of  the  gums  and  the  sensitive  dentine 
were  due  to  the  acid  retention.  The  skin,  lungs,  and  mucous 
membranes  try  to  dispose  of  the  surplus.  If  these  structures  are 
unable  to  do  so,  they  are  expelled  as  gas,  vomit,  or  fermentative 
stools.  That  the  acid  excess  of  the  system  does  pass  through  the 
mucous  and  salivary  glands  of  the  mouth  to  produce  destruction 
of  tissue,  has  already  been  demonstrated.  With  these  illustra- 
tions of  tissue  in  the  mouth  the  question  arises  how  far  does  this 
acidity  affect  other  tissues  and  diseases  of  the  body?  For  want 
of  time,  merely  a  few  urinalyses  in  diseases  were  made. 

Disease.  Degree  of  Urinary  Acidity. 

Arthritis    (rheumatoid) One  70. 

Backache    (severe) One  10 ;  one  25  ;  two  30 ;  one  35 

one  36 ;  .one  40 ;  one  50 ;  one  79 
one  82 ;  one  87 ;  one  90 ;  one  95 
two  100 ;  two  110 ;  one  120. 

Bronchitis    One  56  ;  one  58 ;  one  60 ;  one  61 ; 

one  67 ;  one  120. 

Constipation    One  25. 

Coryza  (acute),  children  3  to  13  yrs.0nel2;  two  13;  one  14;  one  15 

one  16 ;  one  17 ;  one  20 ;  one  22 
one  26 ;  one  27 ;  one  30 ;  one  36 
one  46;  one  47;  one  50;  one  56 
three  58 ;  one  70 ;  one  72 ;  one  90 

Cystitis  (acute) One  50. 

Diphtheria One  28. 

Dipsomania   One  44. 

Eczema  (hands) One  50;  one  80. 

Enlarged  prostate One  100. 

Enterocolitis  (chronic) One  35  ;  one  80  ;  one  110;  one  112 

Exoplithalmic  goiter  (pnl)erty  stress)  One  54. 

Fibrillae  tremor One  21. 

Gastric  hyperchloridice One  60. 

Gonorrhea   One  120. 

Grippe    Two  25  ;  one  40 ;  one  50 ;  one  60 

one  75;  one  76;  one  80;  one  82 
one  88;  one  90;  one  94;  one  97 
one  110. 

Hypertrophic  rhinitis  (acute) One  21 ;  one  25;  one  113. 


URINARY    SIGNS    OF    AUTOINTOXICATION.  255 

Hypertrophic  rhinitis   (chronic) ....  One  32;  one  57;  one  90. 

Laryngitis    (chronic) One  6o  ;  one  85. 

]^Iiddle  ear,  inflammation  of One  25  ;  one  32  ;  one  90. 

Middle  ear,  chronic  snppnrative  in- 
flammation of One  90. 

Meniere's  disease One  65. 

oNIigraine One  40. 

]\Iyocarditis    (chronic) One  80;  one  100;  one  112. 

Neuralgia  following  grip One  20 ;  one  24 ;  one  25  ;   one  27  ; 

one  40 ;  one  46. 

Pneumonia One  18 ;  one  26 ;  one  27 ;  one  33. 

Pregnancy One  10 ;  one  12 ;  one  14 ;  one  16 ; 

one  18 ;  one  29 ;  one  30 ;  one  50 ; 

one  57;  one  60;  one  62;  one  64; 

one  67;  one  82;  one  84. 

one  82;  one  84. 
Rheumatism  and  gout One  14 ;  one  15  ;  one  18  ;  one  19  ; 

one  20 ;  one  24 ;  one  27 ;  one  35 ; 

one  52;  one  57j  one  61;  one  67; 

one  70. 
Rheumatism   and   heart   trouble,    8 

years  of  age One  40. 

Scarlet  Fever One  33  ;  one  80. 

Sciatica One  55  ;  one  108  ;  one  132. 

Sphenoid  sinus,  inflammation  of .  .  .  .  One  57. 

Sunstroke One  20. 

Tired  feeling One  25  ;  one  40. 

Tonsilitis  (ulcerating) One  10;  one  12;  one  14;  one  20; 

one  27 ;  one  48 ;  one  72. 
Tuberculosis    One  16 ;  one  20 ;  one  21 ;  one  36 

one  44 ;  one  52 ;  one  56 ;  one  78 

one  81;  one  88;  one  102;  one  108 

one  115 ;  one  142. 

Tuberculous  hip  disease One  80. 

Typhoid  Fever One  76  ;  one  88  ;  one  90 ;  one  109  ; 

one  120. 
Urticaria    One  47. 


On  comparing  the  office  patients  with  those  of  other  special- 
ists and  patients  ill  at  home  or  in  a  hospital,  it  is  found  that  the 
degree  of  acidity  does  not  vary  to  any  great  extent.  A  constant 
abnormal  degree  of  urinary  acidity,  in  an  individual  attending 
to  his  affairs,  means  that  sooner  or  later  an  organ  or  structure 
is  bound  to  give  way.  This  is  particularly  true  at  the  senile 
period  of  stress  (about  sixty)  when  the  arteries  degenerate.  The 
victim  of  an  abnormal  degree  of  acidity  is  more  subject  to  dis- 
ease than  one  with  normal  acidity.  Study  of  the  effects  of  a  high 
degree  of  acidity  in  an  otherwise  normal  individual  whose  teeth 


256  INTERSTITIAL    GINGIVITIS. 

and  alveolar  xjrocess  are  being  destroyed  lias  exceedingly  inter- 
esting results. 

Lessened  blood  alkalinity  affects  the  whole  alveolar  process 
by  setting  up  an  irritation  and  inflammation  of  the  coats  of  its 
arterioles  and  in  the  tooth  pulp,  producing  endarteritis  oblit- 
erans, arteriosclerosis,  and  nerve-end  degeneration.  I  have  dem- 
onstrated those  diseases  many  times.  Disease  of  the  terminal 
nerves  and  arteries  causes  absorption  of  the  bone.  The  inflam- 
matory process  has  been  termed  interstitial  gingivitis ;  the  bone 
absorption,  osteomalacia,  or  senile  absorption,  although  it  may 
occur  early  in  life. 

May  not  osteomalacia  in  other  parts  of  the  body  be  due  to  the 
same  cause? 

Cylindruria  ^  is  not  necessarily  associated  with  definite  path- 
ologic alterations  of  the  renal  parenchyma.  This  statement 
should  likewise  be  accepted  as  to  the  occurrence  of  purely  hyaline 
casts  and  their  presence  in  small  numbers.  A  few  renal  epithe- 
lial cells  may  be  found  at  the  same  time  occurring  either  in  the 
urine  or  adhering  to  the  casts,  but  never  presenting  an  atrophic 
or  otherwise  altered  appearance  in  the  absence  of  definite  renal 
lesions.  The  presence  of  compound  hyaline  and  coarsely  gran- 
ular casts,  as  well  as  of  waxy  and  amyloid  casts,  on  the  other 
hand,  may  be  regarded  as  indicating  definite  changes  in  struc- 
ture, so  that  as  far  as  diagnosis  is  concerned  microscopic  exam- 
ination of  the  urine  furnishes  information  of  more  value  than  the 
simple  demonstration  of  albumin. 

Hyaline  casts  are  more  frequently  seen — reference  is  here 
made  only  to  the  purely  hyaline  or,  at  least,  but  faintly  granular 
form — and  are  found  in  all  conditions  in  which  albuminuria 
occurs.  When  present  in  only  small  numbers,  and  particularly 
when  occurring  but  temporarily  in  the  urine,  it  may  be  assumed, 
in  the  absence  of  other  symptoms  pointing  to  renal  disease,  that 
there  is  a  mild  circulatory  disturbance  of  the  kidneys. 

The  significance  of  blood  and  epithelial  cells  imbedded  on 
hyaline  casts  is  the  same  as  the  significance  of  blood  and  epithe- 
lial casts ;  both  are  pathologic  and  indicate  nephritis. 


Clinical  Diagnosis,  p.  620. 


UEINARY   SIGNS   OF   AUTOINTOXICATION.  257 

Fine  granular  and  hyaline  casts  often  occur  from  auto-toxic 
strains  on  congenitally  insufficient  kidney  in  arthritic  and  allied 
states. 

The  presence  of  albumin  in  these  cases  was  exceptional,  it 
being  found  in  but  four  cases.  This  would  show  that  in  none  of 
these  cases  had  the  disease  become  very  marked.  When  present 
it  does  not  in  itself  indicate  grave  disorder,  since  albumin  may 
be  due  to  many  conditions  of  the  renal  tract.  It  is  of  interest 
to  us  since  disturbance  of  circulation  may  bring  about  albu- 
minuria without  inducing  structural  change  in  the  kidneys. 
Purdy  says:  ''Circulatory  disturbances,  in  order  to  induce 
albuminuria,  must  include  the  renal  vessels.  In  nature  they 
must  consist  of  acceleration  of  the  arterial  current  or  slowing 
of  the  venous  current,  in  either  case  resulting  in  increased  blood 
pressure.  Again,  in  some  derangements  of  the  nervous  system 
which  interfere  with  the  vasomotor  nerve  regulation  of  the  renal 
vessels,  temporary  albuminuria  is  not  an  uncommon  result." 
Albuminuria  is  present  in  auto-toxic  neurasthenia,  epilepsy, 
paretic  dementia,  and  the  renal  crises  of  locomotor  ataxia. 

The  specific  gravity  ranges  from  1.005  to  1.031.  The  normal 
specific  gravity  ranges  from  1.015  to  1.025.  The  difference  de- 
pends upon  the  amount  of  solids  and  fluids  present,  increasing 
as  the  solids  increase,  decreasing  as  the  amount  of  fluids  increase. 
Specific  gravity  is  hence  an  index  in  a  general  w^ay  of  metabolic 
change.  The  low  degree  of  acidity  would  indicate  that  a  certain 
amount  of  acid  was  circulating  throughout  the  system. 

Indicanuria  denotes  the  presence  in  the  urine  of  potassium 
indoxyl  sulphate  formed  by  metabolism  of  indol  absorbed  from 
the  intestines.  It  is  supposed  to  be  due  to  three  sources :  First, 
to  intestinal  putrefaction  of  nitrogenous  substances;  second,  to 
suppuration  in  some  part  of  the  body;  and  third,  to  the  forma- 
tion of  indol  in  the  cells  of  the  body-tissues.  The  fact  that 
indican  is  found  in  the  urine  is  a  sufficient  indication  that  this 
poison  has  circulated  in  the  blood  throughout  the  entire  system 
and  has  been  returned  to  the  kidneys  to  be  expelled.  I  have  dem- 
onstrated many  times  that  indicanuria  and  neurasthenia  are  in 
some  way  related.  Reducing  the  intestinal  putrefaction  by  the 
use  of  intestinal  antiseptics,  the  neurasthenic  condition  of  the 


258  INTERSTITIAL    GINGIVITIS. 

patient  is  often  relieved.  The  toxic  effect  of  acidosis  and  indican 
upon  local  tissues,  especially  upon  terminal  and  transitory 
structure,  is  very  marked.  Their  injurious  effects  consist  of 
irritation  of  the  coats  of  the  blood-vessels  and  changing  the 
chemical  quality  of  the  red  blood  cells.  The  salivary  glands,  the 
mucous  glands,  the  alveolar  process,  and  the  dental  pulp  are  the 
first  structures  to  become  involved. 

Indicanuria  is  one  of  the  great  sources  of  autointoxication. 
The  toxins  of  indican  permeate  all  the  structures  of  the  body, 
being  carried  by  the  blood  circulation.  While  acidosis  and  in- 
dicanuria may  go  hand  in  hand,  the  quantity  of  indican  depends 
to  a  certain  extent  upon  the  acidosis  relative  to  the  amount 
formed  in  the  intestines.  Thus,  upon  reducing  a  high  degree  of 
urinary  acidity  to  normal  or  below,  the  indican  will  be  increased, 
owing  to  the  abnormal  bacterial  activity  in  producing  putrefac- 
tion. These  germs  seem  to  thrive  better  in  alkaline  than  in  acid 
media. 

An  accumulation  of  indican  in  the  organism  will  often  cause 
febrile  disturbances,  lassitude  and  gastrointestinal  irritation — 
depending,  of  course,  upon  the  severity  of  the  attack.  The 
effect  of  indican  is  not  unlike  that  of  poisonous  drugs  such  as 
mercury,  lead,  phosphorus,  bromine,  quinine,  etc.,  which  pro- 
duce poisonous  symptoms  in  some  individuals.  In  others  there 
are  apparently  no  ill  effects.  It  must,  therefore,  not  be  over- 
looked that  in  all  persons  with  persistent  indicanuria  the  poison 
is  continuously  absorbed  from  the  intestines  into  the  circulation 
for  months  and  years,  and  that  in  many  persons  it  mil  not  mani- 
fest itself  until  the  periods  of  stress  at  forty-five  and  again  at 
sixty  years  of  age.  Metchnikoff,  in  considering  the  phenomena 
of  old  age,  concludes  that  autointoxication  due  to  intestinal 
putrefaction  is  one  of  the  most  important  causes  of  premature 
senility,  in  that  it  causes  arteriosclerosis.  The  accumulation  of 
these  toxins  in  terminal  organs,  such  as  the  pulp  and  alveolar 
process,  is  as  disastrous  as  the  accumulation  of  any  of  the  poison- 
ous drugs.  Arteriosclerosis  is  one  of  the  common  diseases  found 
in  the  alveolar  process  and  in  the  pulp,  which  is  a  positive 
proof  of  its  systemic  origin. 

To  obtain  the  amount  of  indican  in  a  given  specimen,  take 


URINARY   SIGNS    OF   AUTOINTOXICATION.  259 

5  ccm.  of  urine;  pour  it  into  a  test-tube;  add  5  ccm.  of  hydro- 
chloric acid,  and  shake  thoroughly.  Let  the  mixture  stand  for  a 
few  moments.  Add  10  drops  of  hydrogen  dioxide,  shake  thor- 
oughly, and  let  it  stand  for  a  few  moments ;  then  add  1  ccm.  of 
chloroform,  shake  thoroughly  again,  and  let  it  stand.  If  indican 
be  present,  chloroform  mil  absorb  it,  turn  blue,  and  settle  to  the 
bottom  of  the  tube ;  if  there  be  no  indican,  the  chloroform  will 
remain  colorless. 

The  toxins  in  the  blood  which  accompany  acidosis  and  indi- 
canuria  are  carried  to  all  structures  of  the  body.  All  structures 
of  the  body,  however,  are  not  alike.  Some,  especially  those  that 
are  active  and  are  needed  for  the  welfare  of  the  body,  under  the 
law  of  economy  of  growth  or  use  and  disuse  of  structures,  can 
take  care  of  tlie  toxins  and  return  the  blood  to  be  cleansed  of  its 
impurities.  Other  structures  which  are  of  little  use,  and  are 
called  terminal  organs  and  transitory  structures,  such  as  the 
dental  pulp  and  the  alveolar  process,  cannot  dispose  of  the 
blood  so  readily.  The  result  of  this  is  an  accumulation  of  tox- 
ins, and  disease  follows.  Other  terminal  organs  that  can  stand 
the  strain  a  little  better,  but  are  sure  to  succumb  later  if  the 
toxins  continue  to  be  present  in  the  blood,  are  the  kidneys,  the 
heart,  the  liver,  the  eye  and  the  brain. 

I  msh  to  call  the  attention  of  the  profession  to  the  fact  that 
early  symptoms  and  systemic  disorders  may  be  recognized,  and 
prophylactic  means  may  be  adopted  to  ward  off  future  trouble. 
Heart-pressure,  endarteritis  obliterans,  arteriosclerosis  and 
dilated  arteries  are  easily  demonstrable  in  the  pulp  and  in  the 
alveolar  process  by  early  symptoms  of  acidosis  and  indicanuria. 
It  will  be  seen,  then,  that  acidosis  and  indicanuria  are  factors 
which  cannot  be  overlooked. 

Critical  examination  of  tables  must  convince  a  careful  ob- 
server that  in  every  examination  two  conditions  are  present; 
first,  autointoxication  due  to  intestinal  fermentations  and  faulty 
elimination  as  represented  by  the  indican  and  an  abnormal  uri- 
nary acidity  degree ;  second,  kidney  over-strain  and  renal  insuf- 
ficiency due  to  hepatic  insufficiency.  When  the  liver  fails  to  de- 
stroy the  poisonous  "materials  and  the  bowels  to  eliminate  the 
toxins,  over-strain  of  the  kidneys  causes  the  blood  to  become 


260  INTERSTITIAL    GINGIVITIS. 

overcharged  with  toxins  and  acidity,  the  heart  and  arteries 
undergo  degenerative  changes,  and  cardiac  hypertrophy  and 
cardio-vascular  diseases,  with  insufficient  blood  supply,  result. 

It  may  be  possible  that  in  the  near  future  other  poisons  than 
those  already  mentioned  will  be  found  in  the  urine,  which  may 
produce  toxic  effects  on  the  alveolar  process.  Since  this  chap- 
ter was  wa-itten,  the  following  appears  in  the  Journal  of  the 
American  Medical  Association:  "A  few  unique  anomalies  of 
metabolism,  notably  alkaptonuria  and  cystinuria,  have  attracted 
attention  quite  as  much  because  of  the  interpretation  w^hich  they 
lend  to  the  normal  disintegration  of  protein  in  the  body  as  on 
account  of  the  pathologic  features  involved.  From  the  fact  that 
certain  diamirs,  cadaverin  and  putrescin,  characteristic  of  the 
putrefaction  of  jjroteins,  frequently  are  found  in  conjunction 
with  cystin  in  the  urine  of  patients,  it  has  at  times  been  assumed 
that  there  is  an  essential  connection  in  cystinuria  between  ali- 
m.entary  putrefactive  changes  and  the  output  of  characteristic 
abnormal  excretory  products.  Cystinuria,  however,  has  been  re- 
garded of  late  rather  as  an  abnormality  of  protein  metabolism 
in  which  the  amino-acid  cystin — a  typical  degradation  product 
of  albuminous  substances — is  not  further  broken  down  and  oxi- 
dized as  ordinarily.  This  view  is  strengthened  by  the  simul- 
taneous finding  of  other  amino-acids,  leucin  and  tyrosin,  in  cer- 
tain cases.  The  latest  novelty  is  the  discovery  of  another  amino- 
acid,  lysin  (diamino-caproic  acid),  in  the  urine  of  a  patient  with 
cystinuria.  Since  this  compound  is  known  to  be  the  mother  sub- 
stance of  cadaverin,  the  intimate  inter-relation  of  the  various 
observed  constituents  is  further  emphasized.  Taken  together, 
the  accumulated  data  strengthen  the  conception  of  cystinuria  as 
a  condition  in  which  the  usual  progress  of  protein  catabolism  is 
profoundly  inhibited.  One  by  one  the  unused  fragments  are 
cropping  out  as  new  cases  become  available  for  study." 


CHAPTER  XXIV. 

AETERIOSCEEROSIS,   ENDARTERITIS    OBLITERANS  AND    NERVE   END 

DEGENERATION. 

Endarteritis  obliterans  and  hypertropliy  of  tlie  middle  and 
outer  coats  of  the  arteries  are  physiologic  processes  concerned 
in  the  disappearance  of  blood  vessels  functional  in  the  fetal 
state,  but  losing  such  function  after  birth.  Like  all  physiologic 
processes  of  the  fetal  type  these  become  pathologic  under  ordi- 
nary conditions  of  post-natal  life.  For  these  reasons  they  again 
become  physiologic  in  the  involutional  periods  like  the  climac- 
teric and  senility.  In  transitory  structures,  like  the  alveolar 
process,  there  is  continual  trembling  between  the  physiologic 
and  pathologic.  Undue  excitation  of  the  structure  brings  on  an 
intensity  of  the  process  which  tends  to  become  pathologic.  As 
I  demonstrated  a  decade  ago,  endarteritis  obliterans  and  hyper- 
trophy of  the  middle  and  outer  coats  of  the  arteries  play  a  large 
part  in  interstitial  gingi^^tis. 

In  consideration  of  this  subject,  the  changes  in  the  elasticity 
of  the  artery  and  vein  walls  and  the  permeability  of  the  capil- 
lary walls  will  be  discussed. 

The  vessel  walls  are  capable  of  great  elasticity  and  bear  the 
tension  of  the  pressure  of  the  blood  A\dthout  sho^^ing  any  condi- 
tion of  being  strained.  This  elastic  function  of  the  walls  is  con- 
trolled by  the  muscular  coat,  which  changes  the  chemic  energy 
of  the  blood  stream  into  energy  of  elasticity  and  in  this  manner 
keeps  the  vessel  walls  in  a  normal  elastic  state.  The  changes 
that  take  place  in  the  arterial  walls  of  the  aortic  system  are  of 
more  or  less  importance,  since  the  normal  elasticity  of  the 
artery  walls,  blood  pressure  regulation,  and  distribution  are 
dependent  upon  the  depth  and  intensity  of  these  changes. 

When  the  vessel  walls  become  diseased  there  may  or  may  not 
be  serious  disturbance  in  the  blood  circulation.  The  acute  and 
chronic  contagions  and  infections,  a  general  nutritional  disturb- 
ance or  poisons  taken  either  internally  or  externally,  and  a  high 


262  INTERSTITIAL    GINGIVITIS. 

blood  pressure  tend  to  weaken  the  arterial  walls  so  that  their 
elastic  tonicity,  in  some  instances,  is  completely  lost. 

This  weakened  elasticity  is  easily  recognized  by  a  distensile 
pulse  and  also  registered  by  the  sphygmomanometer.  At  the 
same  time,  arterial  murmurs  can  be  heard  in  the  large  arteries, 
especially  the  femoral,  which  are  apparently  a  result  of  the 
rapid  vascular  changes  characteristic  of  a  high  pulse.  A  pulse 
sometimes  observed  in  retinal  arteries  can  also  be  attributed  to 
this  source. 

In  the  conditions  just  mentioned  there  are  no  great  circula- 
tory disturbances,  but  there  is  a  tendency  to  change  in  tlie  struc- 
ture of  the  arterial  walls.  As  a  result  of  this  w^eakened  state,  the 
lumen  expands  and  a  larger  amount  of  blood  flows  through  the 
artery,  but  its  rapidity  is  decreased.  So  with  the  alveolar  pro- 
cess, the  arteries  and  veins  inclosed  within  bony  walls  have  little 
or  no  expansion,  hence  the  tissues  become  more  susceptible  to 
poisons  and  toxins  circulating  in  the  blood  stream.  The  de- 
creased flow  of  the  blood  stream,  in  turn,  causes  new  connective 
tissue  to  form  in  the  intima  of  the  artery,  which  thickens  this 
outer  coat,  making  it  less  elastic  and  reducing  the  pulse  move- 
ments. 

Any  arteries  of  the  body  are  liable  to  become  involved,  but 
more  particularly  those  of  the  extremities  and  end  organs.  While 
puberty  changes  may  produce  a  severe  attack,  the  condition  is 
more  frequently  noticed  later  in  life — the  later,  the  more  pro- 
nounced. Men  are  more  subject  to  the  disease  than  women  ow- 
ing to  the  fact  that  women  eliminate  much  more  freely  than 
men,  and  because  they  are  not  often  subjected  to  drug  poisons. 
Coldness  of  the  limbs,  hard  whip-cord  arteries  with  no  pulsa- 
tion, and,  in  extreme  cases,  gangrene  of  the  extremities  result. 
The  disease  begins  in  the  intima  and  extends  to  the  other  coats 
of  the  artery.  It  may  be  found  in  all  local  inflammations  of 
long  standing,  especially  in  the  extremities,  the  alveolar  process, 
and  may  occur  in  conditions  of  vasomotor  ataxia,  such  as  are 
present  in  Raynaud's  disease  and  allied  conditions.  Syphilis, 
tuberculosis,  typhoid  fever,  scurvy,  and  the  condition  underlying 
arterio-capillary  fibrotic  kidney  lesions  act  at  times  as  predis- 
posing causes.    Toxins  and  autotoxic  products  of  retained  waste 


ARTEKIOSCLEROSIS,    AND    NERVE    END    DEGENERATION.  263 

may  disturb  physiologic  balance,   thus  giving  the   pathologic 
phase  of  this  disorder  sway. 

Endarteritis  is  an  inflammation  of  the  internal  coat  of  an 
artery  or  capillary,  generally  of  chronic  type.  Its  pathogeny  is 
as  follows:  In  direct  contact  with  the  blood  streams  is  the 
endothelium  (a  layer  of  flattened  cells) ;  next  is  the  tunica 
intima,  composed  of  elastic  fibers  arranged  longitudinally ;  next 
comes  the  middle  coat,  composed  of  muscular  fibers  arranged 
transversely.  The  outer  coat  consists  of  longitudinal  connective 
tissue,  which  contains  the  vasa  vasorum.  In  the  capillaries,  the 
intima  lies  in  immediate  contact  with  the  surrounding  tissues,  or 
accompanied  by  a  rudimentary  adventitia.  In  other  words,  the 
walls  of  the  capillaries  consist  of  almost  nothing  but  the  intima. 
The  capillaries  have  certain  contractility;  they  contract  or 
dilate  without  muscular  fibers.  The  veins  probably  also  have  a 
certain  amount  of  contraction  and  dilatation  from  irritability  of 


Fig.  79. — Endarteritis  Obliterans  (Kaufmann). 
A,  Adventitia.     E,  Elastic  Tissue  between  Middle  Coat  and  Intima.     M,  Muscular. 

J,  Thickened  Intima. 

the  intima.    Each  coat  of  the  arteries  takes  on  a  special  type  of 
inflammation.    The  causes  of  endarteritis  are  numerous. 

Inflammation  of  the  intima  of  the  blood  vessels  may  be  due 
to  irritation  from  without  or  within.  When  it  occurs  from  with- 
out, any  local  irritation  will  set  up  an  inflammation  which  may 
extend  to  the  outer  coats  of  the  capillaries.  This  produces  a 
marked  increase  of  blood.  The  vasa  vasorum  become  swollen, 
the  white  blood  corpuscles  crowd  into  the  terminal  capillaries 
and  migrate  into  the  extra  vascular  space.  Rapid  proliferation 
of  the  round-cell  elements  takes  place.  The  walls  of  the  vessels 
become  thickened.  Owing  to  the  projecting  intervals  of  the 
intima,  the  caliber  of  the  blood  vessels  diminishes  (Fig.  79). 


264  INTERSTITIAL    GINGIVITIS. 

Irritation  occurring  from  within,  results  either  from  trophic 
changes  in  the  system  from  direct  irritation  from  toxaemias,  or 
from  both  interdependently.  Under  these  circumstances  toxins 
may  have  an  affinity  for  a  certain  organ,  tissue  or  part,  and  pro- 
duce irritation  in  the  capillaries  in  a  distinct  part  of  the  body, 
or  the  capillaries  through  the  entire  body  may  become  involved. 
Thus,  in  typhoid  fever,  the  Peyer's  gland  in  the  intestine  be- 
comes involved;  in  scarlet  fever,  the  skin  or  kidney;  in  malaria, 
the  liver  and  spleen;  in  Bright 's  disease,  the  kidney;  while  in 
mercurial  and  lead  poisoning  and  scurvy,  the  mucous  membrane, 
and  especially  the  gums,  become  diseased.  In  many  of  these  con- 
ditions, however,  before  the  tissue  already  irritated  becomes 
involved,  the  nervous  system  has  become  affected.  The  nervous 
system  may  already  have  become  affected  from  other  causes. 
Thus,  locomotor  ataxia,  traumatic  injuries  to  the  spine,  paretic 
dementia,  cerebral  paralysis,  neuroticism  and  degeneracy,  and 
last,  but  not  least,  stomach  neurasthenia.  The  poison  in  the 
blood,  together  with  the  diseased  peripheral  nerves,  produce  irri- 
tation and  inflammation  of  the  inner  coat  of  the  capillaries.  If 
this  irritation  does  not  disappear  soon  after  its  inception, 
the  inflammation  tends  to  affect  the  other  coats  of  the 
blood  vessels.  Under  certain  conditions,  endarteritis  may, 
however,  never  involve  the  other  coats  of  the  vessels.  When 
irritation  of  the  inner  coat  of  the  capillaries  takes  place, 
proliferation  of  the  endothelium  occurs.  This  inflammatory 
growth  tends  to  obstruct  the  lumen  of  the  vessel.  The  media 
may  likewise  become  thickened  by  an  increased  connective  tissue. 
The  capillaries  become  obstructed,  and  finally  obliterated.  This 
finally  impedes  the  circulation.  Fig.  80  shows  such  a  condition 
in  the  scurvy  case,  elsewhere  illustrated. 

Irritation  may  be  of  less  intensity  but  greater  duration,  as  in 
cases  of  syphilis,  tuberculosis,  scurvy,  mercurialism,  plurabism 
(lead  poisoning),  etc,  and  the  results  are  then  slowly  effected. 
Proliferation  of  sub-endothelial  connective  tissue  gradually 
increases  until  it  reaches  its  limit  (endarteritis  obliterans).  This 
influence  of  the  proliferation  is  exerted  in  addition  to  that  of  the 
round-cell  infiltration  about  the  structure. 


ARTERIOSCLEROSIS,    AND    NERVE    END    DEGENERATION. 


265 


The  recent  studies  of  Hektoen^  on  meningeal  tuberculosis 
demonstrate  that  tubercle  bacilli  may  penetrate  the  unbroken 
endothelial  layers  of  the  vessel  and  stimulate  marked  prolifera- 
tion of  the  sub-endothelial  connective  tissue.  An  internal  irri- 
tant, such  as  may  be  produced  in  the  course  of  any  infectious  dis- 
ease or  from  sul)oxidation,  probal3ly  acts  upon  the  endothelium 
of  the  walls  of  the  smaller  blood  vessels  in  such  a  way  as  to  per- 
mit the  escape  through  the  walls  first  of  serum,  then  of  leuco- 


X    150.   D.   D.   obj.     Zeiss. 
Fig.   80. — Cross   Se(tion   of   Peridental   Membrane,   Showing   Endarteritis 
Obliterans.     Scurvy  in  Man. 
C,  Cementum.     D,  Dentine.     I,  Peridental  Membrane.     IT,  Nerve  Tissue.     EO,  Endar- 
teritis Obliterans. 

cytes,  the  latter  infecting  and  surrounding  the  vessels.  The  effect 
of  the  chronic  endarteritis  is  to  check  the  blood  supply  to  the  gum 
tissue.  Mercury,  lead  and  other  poisons  circulating  through  the 
blood  are  forced  to  remain,  hence  discoloration  of  tissue  along 
the  gum  margin.  Interstitial  gingivitis,  resulting  in  a  slow  dis- 
turbance of  nutrition,  produces  overgrowth  of  connective  tissue. 
In  all  cases  of  chronic  interstitial  gingivitis,  as  shown  in  the  illus- 
tration, are  the  blood  vessels  thus  involved. 


*  American  System  of  the  Practice  of  Medicine,  page  119. 


266 


INTERSTITIAL    GINGIVITIS. 


Among  the  predisposing  influences  which  canse  this  disease 
are  syphihs,  tuberculosis,  mercurialism,  phimbism,  brass  poison- 
ing, lithasmia,  nephritis,  gout,  rheumatism,  alcoholism,  scurvy, 
nervous  diseases,  pregnancy  and  old  age.  Under  certain  con- 
ditions of  the  system  any  and  all  diseases  which  tend  to  lower  the 
vitality,  producing  anaemia,  will  assist  in  producing  this  disease. 
The  direct  cause  may  be  resultant  overstrain  of  the  blood  vessels. 

Owing  to  obliteration  of  the  arterioles  in  the  alveolar  process 
stasis  of  blood  must  follow.  The  detritus  from  the  alveolar  proc- 
ess, therefore,  must  remain  in  the  tissue  and  collect  upon  the 
roots  of  the  teeth. 


Fig.  81. — Longitudinal  Section  op  Gingival  Border,  Higher  Magnification,  Show- 
ing Eound-Cell  Inflammation  Extending  to  the  Inner  Coat  of  the  Blood 
Vessel,  and  also  Plasma — -Mast  Cells. 

Endarteritis  obliterans  and  arteriosclerosis  of  the  blood 
vessel  walls  in  the  alveolar  process  are  always  observed  in  con- 
nection with  both  local  and  constitutional  diseases. 

No  structure  aifords  such  a  favorable  opportunity  for  the 
study  of  endarteritis  obliterans  and  arteriosclerosis  as  the  alve- 
olar process  in  animals  and  human,  since  it  can  be  obtained  in 
quantities  at  all  times  and  under  all  conditions.  It  may  be  pro- 
duced in  healthy  animals  by  the  internal  administration  of  drugs, 
metals  and  other  poisons. 


AETERIOSCLEKOSIS,    AND    NERVE    END    DEGENERATION".  267 

My  researches  on  this  series  of  experiments  were  made  upon 
humans,  monkeys,  and  dogs.  Decalcification  of  the  alveohir  proc- 


FiG.   82. — Arteriosclerosis   in  Tuberculous   Monkeys. 

ess  was  made  in  weak  acid  solution  and  prepared  for  the  micro- 
scope in  the  usual  way. 


Fig.  83.— Transverse  Section  of  Alveolar  Process,  Chronic  Inflammation  Ex- 
tending Throughout.     Dog. 

On  the  administration  of  drugs,  especially  mercury  or  lead, 
to  healthy  young  dogs,  inflammation  of  the  alveolar  process  with 


268 


INTERSTITIAL    GINGIVITIS. 


diseased  arterial  walls  is  seen  at  the  end  of  a  month  or  six  weeks. 
Fig.  81  shows  the  commencement  of  the  thickening  of  the  intima 
in  a  dog.  The  coats  of  the  arteries  are  well  defined  and  the  in- 
flammatory process  has  jnst  begun.  Examination  of  the  alveo- 
lar process  of  animals  or  human  beings  suffering  from  disease, 
in  which  the  eliminating  organs  are  not  throwing  off  effete  mat- 


FiG.  84. — Arteriosclerosis  and  Obliterans  in  Arteries  of  a  Dog  with 
Interstitial  Gingivitis. 

ter,  especially  in  syphilitic,  tuberculous  and  scorbutic  patients, 
easily  reveals  this  morbid  state. 

Fig.  82  is  a  poor  illustration  of  the  disease  in  pregnancy.  If 
such  patients  are  degenerates  the  process  will  be  exaggerated. 

Fig.  83  illustrates  endarteritis  obliterans  in  the  artery  of  a 
dog  with  interstitial  gingivitis. 

Fig.  84  is  from  the  alveolar  process  of  a  tuberculous  monkey. 


Fig.  85. — Arteriosclerosis  from  Mercurial  Poisoning. 


Fig.  86. — Arteriosclerosis  from  Lead  Poisoning. 


270 


INTERSTITIAL    GINGIVITIS. 


Fig.  85  illustrates  the  closing  of  three  arteries  from  mercurial 
poisoning. 

Fig.  86  shows  endarteritis  obliterans  with  arteriosclerosis  in 
interstitial  gingivitis  from  lead  poisoning. 


Fig.  87. — Arterio-sclerosis  and  Obliterans   from   Diabetes   Mellitus. 

Fig.  87  shows  arteriosclerosis  and  endarteritis  obliterans  in 
interstitial  gingivitis  from  diabetes  mellitus. 


Pig.  88. — Arteriosclerosis  and  Obliterans  from  a  Syphilitic. 

Fig.  88  illustrates  arteriosclerosis  of  three  arteries  in  a  syph- 
ilitic. 

It  will  be  seen  from  the  illustrations  that  these  pathologic 
conditions  in  the  blood  vessels  of  the  alveolar  process  produce 
stasis  of  blood  which  cuts  off  the  nutrition  of  the  tissues.  This, 
in  turn,  not  only  lowers  the  vitality  of  the  parts,  but  together 
with  local  disturbances  causes  rapid  destruction  of  the  gums, 
peridental  membrane  and  alveolar  process. 


AETEEIOSCLEROSIS,    AND    NERVE    END    DEGENERATION.  271 

NERVE  END  DEGENERATION. 

Since  the  brain  presides  over  development  of  the  tissues  of 
the  body  through  its  trophic  and  vasomotor  systems,  it  must  be 
as  fully  developed  and  normal  in  construction  as  possible  so  that 
body  tissues  may  develop  normally.  Pleasure,  happiness  and 
laughter  aid  digestion,  while  melancholia  and  grief  may  retard 
growth  and  function  and  produce  tropho-neuroses.  An  unstable 
nervous  system  produces  unstable  tissues,  i.  e.,  either  excessive 
or  arrested. 

While  the  nervous  system  has  other  special  functions,  the  one 
great  object  is  that  of  regulating  growth  and  repair.  As  Mari- 
nesco  has  shown,  this  function  resides  even  in  the  neuron  or 
nerve  unit.  Growth  and  repair  are  regulated  through  the  trophic 
and  vasomotor  systems.  In  the  domain  of  bone  growth,  trophic 
nerve  anomalies  were  first  observed.  Brown-Sequard  demon- 
strated anomalies  in  tabetic  joints  of  sufferers  from  locomotor 
ataxia  and  later  similar  states  were  observed  in  the  jaws.  An- 
other allied  neurosis,  paretic  dementia,  presents  similar  trophic 
disturbances,  as  Kiernan  pointed  out  thirty-five  years  ago.- 

Among  these  tropho-neuroses  is  one  characterized  by  loosen- 
ing and  falling  out  of  the  teeth  by  alveolar  resorption,  gingival 
ulceration  and  perforation,  with  at  times  maxillary  necrosis. 
This  condition  has  long  been  recognized  by  alienists  and  neurol- 
ogists as  causing  that  loss  of  the  teeth  which  occurs  in  paretic 
dementia,  locomotor  ataxia  and  diabetes.  This  function  of  the 
trophic  nerves,  as  I  have  elsewhere  shown,  has  received  but  little 
attention  from  dentists,  albeit  its  influence  has  been  recognized 
in  dental  pathology  in  connection  with  the  great  neuroses  in 
which  gum  disorder  occurs,  followed  by  a  loosening  of  the  teeth. 

Degeneration  of  the  peripheral  nerves  due  to  interruption  of 
the  connection  with  the  central  nervous  system  was  first  shown 
by  Nasse  and  Valentine  in  1839.  Not  until  1850,  however,  was  a 
thorough  study  made  of  nerve  degeneration  by  Waller,  the 
pathology  of  which  is  now  known  by  his  name.  Wallerian  degen- 
eration implies  change  in  the  terminal  ends  of  the  peripheral 
nerves  after  they  have  been  cut,  which  consists  in  coagulation  or 


"Journal  of  Nervous  and  Mental  Diseases,   1878. 


272  INTERSTITIAL    (MN(;i\^ITIS. 

breaking  np  of  tlie  myelin  sheatli,  destruction  of  the  axis  cylin- 
der, tlie  neurilemma  with  its  nuclei  remaining  for  some  time  pre- 
served. If  a  sensory  nerve  be  cut  through  peripheral  to  the 
spinal  ganglion  complete  degeneration  ensues. 

Similar  experiments  showed  that  if  the  dorsal  root  of  a  spinal 
nerve  be  cut  through  at  a  point  between  the  ganglion  and  the 
spinal  cord  the  portion  of  the  nerve  attached  to  the  ganglion  did 
not  undergo  the  typical  degeneration,  while  the  portion  still  con- 
nected with  the  cord  showed  the  characteristic  degeneration  phe- 
nomena which  could  be  traced  throughout  the  whole  course  of  its 
constituent  fibers  in  the  dorsal  funiculi  of  the  cord.  The  cells  of 
the  spinal  ganglia  have  therefore  been  looked  upon  as  trophic 
centers  for  the  peripheral  sensory  nerves  and  their  intramedul- 
lary continuations. 

Similar  degenerations  in  the  domain  of  the  central  nervous 
system  likewise  occur ;  secondary  descending  degeneration  of  the 
pyramidal  tract,  established  by  Turck,  and  ascending  secondary 
degeneration  in  the  spinal  cord  after  transverse  lesion  being 
analagous. 

Converting  then,  as  Barker^  remarks,  the  Wallerian  doctrine 
into  terms  of  the  neuron  concept,  the  following  general  law  may 
be  laid  down:  "Whenever  it  has  suffered  a  solution  of  continu- 
ity, with  severing  of  its  connection  with  the  cell  body  and  den- 
trites  of  the  neuron  to  which  it  belongs,  the  axon,  together  with 
the  myalin  sheath  covering  it,  undergoes  in  the  part  distal  to  the 
lesion  acute  and  complete  degeneration.  This  degeneration 
includes  not  only  the  main  axon,  but  also  its  terminals,  together 
witli  the  collaterals  and  their  terminals  connected  with  it." 

Some  investigations  have  shown  that  the  slightest  injuries  to 
nerve  cells  or  neura  will  give  rise  to  easily  demonstrable  degen- 
erative lesions  in  other  parts  of  the  cell.  The  most  significant 
instance  is  in  lateral  sclerosis,  where  the  pyramidal  motor  cells 
of  the  cortex  show  no  marked  lesions,  though  the  most  distal  por- 
tions of  the  nerve  fibers  arising  from  them  have  gradually 
degenerated. 

In  some  peripheral  nerve  diseases,  according  to  Strumpell, 


The  Nervous  System.    Barker. 


AKTERIOSCLEKOSIS,    AND    NEEVE    END    DEGENERATION.  273 

the  degeneration  of  the  distal  portion  of  the  axones  may  be  due 
to  direct  action  of  toxins  exerting  a  deleterious  influence  upon 
the  cell  body  or  the  whole  neuron.  In  WoUenberg's  opinion  the 
primary  type  of  disease  of  the  sensory  neura  in  tabes  is  of  this 
kind. 

As  Sidney  Knli*  has  shown,  in  some  of  the  toxic  forms,  as  for 
instance  in  neuritis  due  to  poisoning  ^yiih  lead  and  arsenic,  the 
cells  of  the  spinal  cord  as  well  as  those  of  the  spinal  gangUa  and 
brain  may  be  diseased,  and  according  to  the  neuron  theory  the 
toxic  substances  attack  these  cells  before  the  nerve  fiber  itself  is 
altered.  Such  an  assumption  explains  why  pronounced  degen- 
eration of  peripheral  nerves  may  occur  without  causing  any  ap- 
preciable symptoms.  Toxins  and  intoxications  will  produce  the 
same  results,  especially  in  those  nerves  extending  into  and 
through  the  alveolar  process.  Pitres  and  Vaillard  first  showed 
that  after  typhoid  fever,  many  nerve  fibers  are  found  degener- 
ated, in  cases  in  which,  during  life,  symptoms  of  neuritis  were  ab- 
sent. The  same  observers  found  like  states  in  the  nerves  of  those 
who  had  died  from  tuberculosis.  Later  observations  have  ex- 
tended these  states  to  such  diseases  as  diphtheria,  syphilis,  alco- 
holism, carcinoma,  inanition,  marasmus,  arteriosclerosis  ^and 
leprosy;  in  the  so-called  rheumatic  neuritis  of  the  facial  nerve 
and  to  inflammation  due  to  articular  rheumatism,  gout,  puerperal 
infection,  tuberculosis,  etc. 

The  method  of  cell  poisoning  has  been  observed  in  other 
intoxications.  Certain  groups  of  neura  are  more  susceptible 
than  others  to  a  given  toxication.  The  same  group  of  nerve 
cells  in  two  individuals  may  react  very  differently  to  similar 
doses  of  the  same  poison.  Syphilitic  toxin  shows  a  decided 
preference  for  certain  parts  of  the  cerebral  cortex,  other  areas 
being  less  affected.  The  nerve  enchngs  in  all  parts  of  the  body 
are  markedly  involved,  especially  those  in  and  about  the  teeth. 
Peripheral  nerve  degeneration  results  where  the  blood  current 
or  the  nerves  themselves  are  involved  from  faulty  metabolism, 
etc. 

Nerve  lesions  more  readily  result  where  nerves  are  confined 
within  restricted  walls  of  transitory  structures  where  the  pulp 


*  American  Medicine,  Vol.  Ill,  No.  21,  pp.  865, 


274  INTERSTITIAL    GINGIVITIS. 

has  degenerated,  especially  in  cases  of  hypercementosis  of  the 
root.  When  degeneration  of  the  peripheral  nerves  in  the  pulp 
takes  place  there  may  at  first  be  pain,  continuously  perceptible 
to  the  patient  or  absent  except  under  manipulation  or  replaced 
by  analgesia.  In  most  cases  there  is  analgesia,  owing  to  the 
peculiar  anatomic  construction  of  the  tooth  and  nerve  degen- 
eration. There  is  loss  of  function.  The  same  condition  exists 
in  the  alveolar  process  when  diseases  or  intoxications  occur,  the 
junction  of  the  peripheral  nerves  is  destroyed,  resistance  is  low- 
ered, disease  of  the  process  and  peridental  membrane  results. 


CHAPTER  XXV. 

ABSORPTION  OF  THE  ALVEOLAE  PROCESS  AND  CALCIC  DEPOSITS  UPON 
THE  ROOTS  OF  THE  TEETH. 

Absorption  of  tlie  alveolar  process  is  the  result  of  irritation, 
resultant  malnutrition,  and  subsequent  inflammation.  The 
osteoblasts  and  osteoclasts  are  ever  present  to  build  up  and 
tear  down  bone  structure  on  the  slightest  provocation.  Hyper- 
trophy (building  up  of  bone  tissue)  is  the  result  of  intermittent 
pressure,  and  atrophy,  or  absorption  of  bone,  is  due  to  constant 
irritation  and  pressure.  As  has  been  elsewhere  shown,  from 
its  transitory  nature  the  alveolar  process  is  unusually  sus- 
ceptible to  these  influences.  The  causes  of  absorption  are  loss 
of  teeth  by  extraction,  undue  pressure  upon  one  or  more  teeth 
from  improper  articulation  (Bomvill),  wedging  and  irregular- 
ity correction,  heat  under  artificial  dentures,  and  interstitial 
gingivitis  of  local  and  constitutional  origin. 

According  to  Kaufmann,  lacunar  absorption  is  the  most 
common  type.  This  may  be  true  in  morbid  anatomy  of  bone 
tissue  generally,  but  it  is  not  true  of  absorption  of  the  alveolar 
process.  On  an  examination  of  hundreds  of  slides  prepared 
from  canine  and  human  jaws  (of  which  characteristic  types  are 
illustrated),  by  far  the  most  common  form  of  absorption  was 
found  to  be  halisteresis.  Perforating  canal  absorption,  which 
Kaufmann  has  ''occasionally  met  ^^dth,"  is  certainly  very  com- 
mon, while  lacunar  absorption  holds  third  position.  This  order 
of  absorption  is  accounted  for  by  the  fact  that  where  structures 
are  transitory,  halisteresis,  as  quickest  method,  follows  by  the 
law  of  the  survival  of  the  fittest.  For  the  same  reason  per- 
forating canal  absorption  should  stand  second.  The  blood  ves- 
sels of  von  Ebner  being  most  numerous,  although  considered 
smaller,  would  naturally  be  the  second  tissue  involved.  As  in 
interstitial  gingivitis,  absorption  of  the  alveolar  process  is  in- 
variablv  due  to  inflammation,  halisteresis  apparently  starts  at 


276  INTERSTITIAL    GINGIVITIS. 

the  larger  Haversian  canals  from  which  this  form  of  absorption 
invariably  originates. 

Interstitial  gingivitis  extends  to  the  alveolar  process  through 
the  periosteum  as  well  as  the  peridental  membrane  (not,  as  den- 
tists usually  believe,  by  way  of  the  peridental  membrane  alone). 
This  is  demonstrated  by  the  illustrations.  The  entire  alveolar 
process  thus  becomes  involved.  The  products  of  inflammation 
extend  through  the  Haversian  canals  (a  path  obviously  evident 
in  pathologic  illustrations),  setting  in  action  the  three  forms  of 
absorption  as  elsewhere  illustrated. 

Halisteresis  Ossiuni  (uoAo?  of  salt,  (rre/yAots^  deprivation)  or 
decalcification,  is  that  process  of  absorption  wherein  solution  of 
the  lime  salts  first  takes  place,  while  the  cartilage  or  matrix 
remains  for  the  time  undisturbed. 

Solution  of  the  lime  salts  begins  at  the  periphery  of  the 
Haversian  canal  and  advances  toward  the  center  of  the  tra- 
beculae.  This  absorption  follows,  as  a  rule,  the  bone  layers. 
Bone  centers  are,  therefore,  usually  the  last  to  be  absorbed. 
Frequently  decalcification  becomes  complete ;  nothing  remaining 
but  the  organic  matrix  or  cartilage.  Finally,  this  is  also  en- 
tirely destroyed.  As  the  osteoblasts  occur  in  the  matrix  or 
cartilage,  it  is  not  difficult  to  understand  that  absorption  may 
extend  far,  yet  restoration  of  the  alveolar  process  may  occur. 
After  destruction  of  the  matrix  such  a  restoration  is  impossible. 
New  fibrous  tissue  may  be  partly  restored,  but  it  is  doubtful  if 
the  alveolar  process  can  be. 

Both  Ziegler  ^  and  Kaufmann  -  divide  osteomalacia  into  senile 
and  juvenile.  The  latter  occurs  most  frequently  during  preg- 
nancy. In  senile  absorption,  after  a  certain  period,  the  entire 
skeleton  is  affected.  The  condition  begins  most  frequently  in 
the  "vertebra^  and  thorax;  later  extending  to  the  extremities." 
In  pregnancy  ''the  pelvic  bones  are  first  involved,  the  process 
then  extends  to  the  other  bones."  It  is  singular  that  the  alveolar 
process  should  have  been  so  much  neglected  by  pathologists, 
since,  in  both  states,  the  alveolar  process  becomes  involved  long 
before  the  bones  of  the  body. 


^  Special  Pathological  Anatomy,  page  151. 
"  Pathologisehe  Anatomie. 


ABSORPTION    AND    CALCIC    DEPOSITS.  277 

This  is  due  to  three  reasons:  first,  to  trophic  changes;  sec- 
ond, to  the  alveolar  process  being  a  transitory  structure;  and 
third,  to  improper  care  of  the  gums  at  these  periods. 

Osteomalacia  occurs  in  the  alveolar  process  much  earlier 
than  at  the  so-called  ' '  senile ' '  period.  It  is  found  at  twenty,  or 
even  earlier,  and  has  been  termed  juvenile  osteomalacia.  At 
any  period  beyond  that  year,  it  occurs  probably  from  the  pre- 
maturely senile  states  of  which  precocity  is  a  type.  The  lost 
tissue  is  regained  often  after  confinement  in  the  ''pregnancy" 
type,  but  is  never  regained  in  the  senile. 

The  causes  which  produce  morbid  decalcification  are  not  thor- 
oughly determined.  Some  believe  it  to  be  due  to  lactic  acid  in 
the  system,  others  attribute  it  to  an  increased  amount  of  carbonic 
acid  in  the  blood.  Eisenhart  believes  it  to  be  due  to  a  want  of 
alkalinity  of  the  blood,  while  von  Recklinghausen  charges  it 
to  a  local  irritation  of  the  vascular  mechanism  of  the  bones.  It 
would  seem,  from  examinations  already  cited,  that,  so  far  as  the 
alveolar  process  is  concerned,  local  irritation  from  biochemic 
changes  in  the  blood,  as  suggested  by  von  Recklinghausen,  is 
the  chief  cause.  Premature  absorption  of  the  alveolar  process 
accompanies  the  movement  of  the  teeth  in  their  correction  or  in 
rapid  wedging.  Frequently  the  alveolar  process  is  never  fully 
restored,  thus  producing  a  predisposing  factor  for  future 
disease. 

Premature  absorption,  or  osteomalacia  of  the  alveolar  proc- 
ess, is  easily  recognized.  A  shrinking  of  the  gums  and  alveolar 
process  exposing  the  necks  of  the  teeth  is  very  conspicuous. 
Frequently  the  gums  and  mucous  membrane  covering  the  alveo- 
lar process  are  quite  red  (this  is  very  noticeable  in  dogs),  and  a 
thinning  of  the  alveolar  process  over  and  between  the  roots  of 
the  teeth.  The  process  of  one  tooth  only  may  become  involved ; 
again  the  process  over  two,  or  the  whole  jaw,  and  again  both 
jaws  become  affected. 

When  osteomalacia  occurs,  either  of  pregnancy  or  senile 
type,  although  the  tissues  be  seemingly  restored  to  health,  struc- 
tural change  has  taken  place  to  such  an  extent  that  it  ever 
remains  a  predisposing  factor  to  interstitial  gingivitis. 

In  I'ig.  41  may  be  seen  the  blood  vessels  of  von  Ebner. 


278 


INTERSTITIAL    GINGIVITIS. 


These  blood  vessels  are  also  to  be  observed  in  Fig.  61.  They 
are  very  common  in  the  alveolar  process  and,  according  to  Volk- 
mann,  are  the  source  of  the  perforating  canals  which  bear  his 
name. 


X  50.     i/i;-iiich  obj.     No.  Oc. 
Fig.  89. — Cross  Section  of  Tooth,  Alveolar  Process  and  Peridental  Membrane, 

C,    Cementum. 


D. 


Showing  Lacunar  Absorption.    Man. 
Dentine.       I,     Peridental     Membrane.       J,     Alveolar     Process. 
O,  Lacunar  Absorption. 


These  canals  run  in  all  directions.  After  absorption  has  gone 
on  to  form  medullary  spaces,  these  canals  penetrate  through  the 
trabeculae  from  one  space  to  the  other  (Fig.  43).  The  position  of 
this  type  of  absorption  in  the  order  of  frequency  comes  from  the 
fact  that,  in  this  disease,  absorption  is  almost  entirely  due  to 
inflammation;  hence  the  blood  vessels  are  the  first  to  become 
involved.  Those  entering  the  Haversian  canals,  being  the  larger, 
are  first  affected,  and  hence  halisteresis  naturally  precedes. 


ABSORPTION     \y\)     CALCIC     DEPOSITS. 


279 


When  irritation  takes  place  in  a  nerve  or  part  of  bone  wliicli 
is  about  to  be  a])sorbed,  niultiniiclear  cells  arise  at  the  border  in 
the  periosteum  and  jjeridental  membrane.  They  attach  them- 
selves to  the  surface  of  the  bony  trabecule^,  xlccording  to  Sud- 
dutii,  ^'the  absorber  and  the  absorbed  must  be  in  touch  with  each 


X  300.     No.  2,  projection  ocular.     D.  I),  obj.     Zeiss. 

Fir,.  90. — Section  of  Peridextal  Membrane,  Showing  Lacunar  Absorption  in  Dog. 

J,  Alveolar  Process.     O,  Lacunar  Absorption.     I^,  Inflamed  Peridental  Membrane. 

other."  Kolliker  has  named  these  cells  ''Osteoclasts,"  which 
term  has  come  into  general  use.  Very  soon  after  these  cells 
make  their  appearance,  cavities  are  seen  in  the  bone  tissue. 
These  cavities  are  called  Howship's  lacunae.  Lacunar  absorp- 
tion, as  elsewhere  shown,  takes  place  as  a  result  of  irritation  and 
overstinnilation.  Fig.  cS9  shows  a  cross  section  of  the  end  of  one 
of  the  buccal  roots  of  Fig.  91.  As  will  be  observed,  this  tooth 
was  held  in  place  by  two  buccal  roots.  As  much  resistance  was 
h'(|iiii-(Ml  of  tliese.  two  I'oots  as  was  formerly  required  of  three. 


280  INTERSTITIAL   (ilNCilVITIS. 

Trritatioii  due  to  excessive  force  in  mastication  was  causing 
absorption.  Round-cell  inflammation  is  not  yjresent  in  the  peri- 
dental membrane.  The  irritation  may  be  continued  until  inflam- 
mation sets  in  and  until  the  bone  is  entirely  al)Sorbed,  as  noticed 
in  Fig.  90.  Small  round-cell  inflammation  is  (juite  noticeable  in 
the  surrounding-  tissue. 

Sometimes  these  lacuiur  may  be  seen  extending  along  the 
entire  length  of  l)one.  As  many  as  thirty-seven  may  be  counted 
in  some  fields  (Fig.  42).  Lacunar  absorption  frequently  so 
extends  through  the  Haversian  canals  as  to  cut  off  pieces  of  the 
alveolar  process.  A  casual  glance  at  Fig.  89  demonstrates  this. 
This  figure  could  be  multixjlied  many  times  from  other  slides. 
These  frequently  come  away  with  the  peridental  membrane  when 
the  tooth  is  extracted.  This  is  often  noticed  in  removing  loose 
teeth  due  to  interstitial  gingivitis.  By  passing  the  finger  over 
the  surface  of  the  root,  the  rough  pieces  of  bone  may  be  easily 
felt. 

Aside  from  the  forms  of  absorption  already  noted,  absor])tion 
of  the  alveolar  process  is  often  seen,  the  result  of  neuropathic 
lesions.  Paretic  dementia,  diseases  of  the  spinal  cord,  low  forms 
of  inflammation,  general  debility  and  traumatism,  together  with 
unhygienic  conditions  of  the  mouth,  are  fruitful  sources  of  in- 
terstitial gingivitis  and  absorption  of  the  alveolar  process.  Ab- 
sorption of  the  alveolar  process  takes  place  also  in  diathetic 
diseases  in  which  the  nervous  system  has  l)een  involved  (syphilis, 
scurvy,   lithaemia,   etc.). 

CALCIC    DEPOSITS. 

There  are  many  instances  in  which  interstitial  gingivitis 
takes  place,  with  absorption  of  the  alveolar  process  and  exfolia- 
tion of  the  teeth,  without  calcic  deposits.  In  such  cases  the  blood 
is  charged  with  only  sufficient  lime  salts  for  the  nourishment  of 
the  body.  The  waste  products  are  carried  off  with  the  excreta. 
In  absorption  of  the  alveolar  process,  inflammation  does  not 
seem  to  extend  to  the  capillaries,  the  result  of  which  is,  tliis 
waste  material  is  carried  into  the  circulation.  In  this  way, 
calcic  material  does  not  collect  in  the  fluids  and  upon  the  teeth. 
In  those  cases  in  which  pus  is  not  present  (there  being  a  lessened 
amount  of  carbonic  acid)  calcic  deposits  rarely  take  ]»lace.     The 


ABSORPTION    AND    CALCIC    DEPOSITS. 


281 


percentage  of  teeth  so  found,  however,  is  not  so  large  as  those 
with  deposits. 

Examination,  by  a  magnifying  glass,  of  a  recently  extracted 
tooth  (with  the  root  covered  with  sernmal  deposits)  shows  the 
lime  deposited  in  a  manner  resembling  that  of  stalactite  forma- 
tion. The  deposits  often  stand  out  distinctly  independent  of 
each  other  (Fig.  91).  This  condition  is  due  to  deposits  from  the 
blood,  resultant  on  biochemic  changes  in  the  inflamed  tissues. 
Blood  stasis  occurs  in  the  gum  tissue,  fibrous  tissue  of  the  perios- 


FiG.  91. — Palatine  Eoot  of  a  Molar  Tooth  Showing  Calcic  Deposits. 

teum,  peridental  membrane  and  alveolar  process,  through  which 
last  much  of  the  blood  circulates.  This  stasis  may  be  consequent 
upon  conditions  varying  from  simple  inflammation  to  disease  of 
the  endothelium,  producing  endarteritis  obliterans. 

The  blood  has  become  surcharged  in  all  constitutional  dis- 
eases, but  more  especially  in  kidney  lesions.  Deposits  occur  in 
the  fluids  and  upon  the  roots  of  the  teeth.  Frequently  the  de- 
posit is  found  only  on  one  side  or  only  at  one  particular  spot 
on  the  side  of  the  root;  again  at  the  apex,  when  the  pulp  is  de- 
stroyed.   It  may  encircle  the  root.     The  inflammatory  process 


282  INTEESTITIAL    GINGIVITIS. 

may  therefore  be  circumscribed  as  to  area  or  the  whole  tissue 
may  be  involved.  The  deposit  is  circumscribed  in  the  area  of 
inflammation.  The  calcareous  matter  absorbed  from  the  alveolar 
process  in  the  immediate  vicinity  of  the  root  is  soon  deposited 
upon  the  root  or  roots  because  of  the  impeded  circulation.''  **  Os- 
sification, as  has  been  well  remarked,  is  an  active  development 
in  which  the  tissues  are  abundantly  supplied  with  blood.  There 
is  a  rapid  cell  proliferation,  and  the  calcareous  matter  forms  an 
intimate  and  permanent  union  with  the  tissues.  Calcification, 
on  the  other  hand,  is  passive,  and  indicates  an  impaired  vitality. 
Calcification  begins  as  a  rule  in  the  interstitial  tissue.  In  regard 
to  the  origin  of  the  calcareous  salts,  it  is  generally  believed  that 
they  come  more  or  less  immediately  from  the  blood,  although 
Rokitansky  supposes  that  they  were  formed  by  a  metamorphosis 
of  the  tissues  involved." 

Calcification  is  due  to  two  varieties  of  causes:  general  and 
local.  The  former  are  dependent  upon  changes  in  the  blood  or 
its  circulation,  due,  for  example,  to  disease  or  senile  change.  In 
composition  the  blood  may  be  so  altered  as  to  contain  an  ab- 
normal amount  of  calcareous  matter.  This  effect  is  most  com- 
monly produced  by  absorption  of  lime  salts  from  osseous  tissues 
which  are  the  seat  of  extensive  caries,  osseous  cancer,  osteo- 
sarcoma or  osteomalacia.  The  calcareous  matter  thus  taken  up 
is  conveyed  to  other  and  often  remote  parts  and  there  deposited, 
constituting  the  ''metastatic  calcification"  of  Virchow.  Kiitt- 
ner,  of  St.  Petersburg,  has  observed  a  rapid  calcification  of 
nearly  all  of  the  small  arteries  as  a  result  of  caries  involving  the 
dorsal  and  lumbar  vertebrae  in  a  nineteen-year-old  boy.  Virchow 
has  observed  a  case  in  which,  as  a  result  of  bone  cancer  (affect- 
ing nearly  all  of  the  larger  bones,  particularly  the  borders  of  the 
vertebrae  and  the  skull),  the  calix  and  pelvis  of  the  kidneys,  the 
lungs,  parenchyma,  and  the  stomach  mucous  membrane  were 
calcified. 

Circulation  of  the  blood  may  be  retarded  and  thus  favor  pre- 
cipitation of  calcareous  matter  normally  held  in  solution.  To 
this  is  chiefly  due  the  frequency  of  calcareous  degeneration  from 
general  loss  of  vitality. 


'Wood's  Handbook  of  Medical  Sciences,  Vol.  1,  page  743. 


ABSORPTION    AND    CALCIC    DEPOSITS.  283 

Calcification  rarely,  if  ever,  depends  upon  general  causes 
alone.  There  is,  as  a  rule,  a  local  influence.  Very  often  this  is 
due  to  pre-existing  chronic  inflammation.  Old  accumulations  of 
pus  and  exudates  are  exceedingly  prone  to  calcification.  The 
deposit  frequently  occurs  also  in  fibrous  walls  surrounding  the 
accumulation.  A  mere  loss  of  function  predisposes  to  calcifica- 
tion. Such  is  the  case  in  and  about  the  tissue  of  the  alveolar 
process.  The  decalcified  material  from  the  alveolar  process  col- 
lects in  the  soft  tissues  as  well  as  upon  the  roots.  In  his  paper 
George  T.  Carpenter  *  asks  the  question :  Can  a  tissue  be  ab- 
sorbed and  still  remain  as  debris  in  the  pocket"?  Such  is  the  con- 
dition found,  and  this  can  be  easily  proven.  Take  the  contents 
of  a  pocket  and  dissolve  it  in  hydrochloric  acid,  add  three  times 
its  bulk  of  water,  to  this  add  ammonia,  which  will  precipitate 
the  phosphate  and  the  calcium.  The  same  results  may  be  ob- 
tained by  rinsing  a  freshly  extracted  tooth  of  a  pyorrhoea  case 
in  cold  water.  With  a  stiff  brush  remove  the  accumulation  and 
place  it  in  a  test  tube,  add  hydrochloric  acid  and  more  water  if 
necessary.  To  this  add  a  solution  of  ammonia  and  the  lime  salts 
are  precipitated. 

Roots  of  teeth  that  have  become  entirely  denuded  of  peri- 
dental membrane  and  bathed  in  pus  accumulate  large  quantities 
of  calcic  deposits  direct  from  the  absorption  of  the  alveolar 
process. 

Difference  of  opinion  exists  as  to  the  nature  of  the  process 
immediately  involved  in  precipitation  of  lime  salts.  The  sim- 
plest and  seemingly  most  logical  explanation  is  that  the  process 
is  similar  to  that  involved  in  the  formation  of  stalactites.  A  cer- 
tain amount  of  calcareous  matter  is  a  normal  constituent  of  the 
blood.  Herein  it  is  held  in  solution  by  carbonic  acid,  always 
present  in  sufficient  quantity  for  this  purpose.  When  the  cir- 
culation is  impeded  the  free  carbonic  acid  (because  of  its  great 
diffusibility)  is  readily  absorbed  by  the  tissues  or  goes  to  form 
new  compounds,  necessitating  a  precipitation  of  the  calcareous 
matter.  Calcareous  matter  may  be  deposited  in  either  a  fibrous 
or  fluid  matrix.  It  shows  a  preference  for  newly  formed  fibrous 
tissue,  particularly  when  this  is  associated  with  old  tissue  under- 


*  Some  Points  on  the  Etiology,  Pathology  and  Treatment  of  Persistent  Pyorrhoea 
Alveolaris. 


284  INTEESTITIAL    GINGIVITIS. 

going  fatty  degeneration  and  absorption.  In  a  fibrous  matrix 
the  infiltration  usually  begins  in  the  intercellular  substance,  but 
may  involve  the  cellular  elements  at  a  later  period.  In  a  fluid 
matrix  (like  pus)  the  granules  are  frequently  deposited  pri- 
marily within  the  cells.  The  process  may  advance  slowly  or 
rapidly.  When  local  causes  exert  the  chief  influence  it  is  more 
limited  in  area  of  invasion  than  when  there  is  a  general  factor 
in  its  production,  as  in  the  metastatic  forms. 

From  research  it  has  been  shown  that  calcic  deposits  (other 
than  tartar)  may  be  due,  in  a  limited  degree,  to  a  direct  deposit 
from  the  blood  vessels  (serumal  deposits  of  Ingersoll)  while  the 
greater  collection  upon  the  roots  of  the  teeth  and  in  the  fluid 
contents  of  alveolar  and  peridental  abscesses,  is  the  deposit  of 
the  absorbed  alveolar  process.  Analysis  of  the  deposits  and  of 
the  alveolar  process  as  observed  in  Chapter  VII,  shows  a  close 
similarity  between  the  two. 


CHAPTER  XXVL 

PYORRHCEA   ALVEOLAR  IS. 

I  have  shown  how  inflammation  of  the  alveohir  process  might 
be  caused  by  mechanical  or  local  irritation  and  substances  within 
the  organism,  without  the  aid  of  external  infection,  namely,  irri- 
tants in  the  blood  stream.  In  the  last  named  group  are  to  be 
included  the  drug  and  metal  poisons,  poisonous  gases,  etc.,  auto- 
intoxication and  metabolic  disturbances  affecting  the  coats  of 
the  blood  vessels.  The  alveolar  process  is  more  easily  affected 
by  these  irritants  which  may  set  up  inflammation  (interstitial 
gingivitis)  in  a  particular  localit}^  and  remain  there,  or  it  may 
spread  and  the  entire  process  become  involved.  The  alveolar 
process  may  be  destroyed  by  interstitial  gingivitis;  it  is  only 
necessary  that  there  should  be  a  low  form  of  inflammation  taking 
place  in  and  about  the  arteries  and  capillaries  to  produce  ab- 
sorption of  bone.  This  is  what  occurs  in  fully  ninety  per  cent  of 
patients. 

When  the  inflammatory  exudate  is  made  up  of  leucocytes, 
there  is  produced  within  the  tissue  small  round-cell  infiltration 
which  becomes  so  thick  as  to  obscure  the  tissue.  When  the 
leucocytes  are  in  large  numbers  upon  the  surface  of  the  mucous 
membrane  about  the  cervical  margin  of  the  alveolar  process 
their  appearance  on  the  inflamed  surface  is  that  of  a  white  fluid 
called  pus.  Owing  to  the  tortuous  position  of  the  blood  vessels 
in  the  alveolar  process,  the  thinnest  part  being  at  the  gingival 
border,  the  inflammatory  process  usually  begins  at  that  point. 
The  pus  germs  collect  at  the  border,  stasis  of  blood  generally 
being  greatest  at  that  locality.  This  leads  to  a  superficial  loss 
of  substance  and  is  known  as  ulceration  or  purulent  catarrh. 
When  the  leucocytes  collect  in  large  numbers,  within  the  tissue, 
and  are  followed  by  liquefaction  and  dissolution,  it  is  called  an 
abscess.  These  various  infections  are  termed  pyorrhoea  alveo- 
laris,  alveolar  abscess  or  peridental  abscess,  according  to  the  na- 
ture and  location- of  the  infection. 


286  INTERSTITIAL    GINGIVITIS. 

Pus  infection  due  to  interstitial  gingivitis,  whether  it  pro- 
ceeds from  the  ulcerated  surface  or  deep  down  in  the  interstitial 
tissues  from  an  abscess,  whether  it  discharges  between  the  gum 
and  root  of  the  tooth  or  upon  the  surface  of  the  jaw,  must  be 
considered  pyorrhcea  alveolaris^  since  the  source  of  the  pus  is 
always  in  connection  with  the  peridental  membrane  lining  the 
socket  of  the  alveolus.  Pyorrhcea  alveolaris,  therefore,  consti- 
tutes the  second  part  of  this  study.  About  ten  per  cent  of  the 
patients  visiting  the  specialist  are  thus  infected. 

Recovery  from  interstitial  gingivitis  and  return  to  normal 
conditions  without  change  in  structure  is  called  restoration. 
Should  the  damage  be  extensive,  and  accumulations  of  cell  and 
liquid  exudate  so  press  upon  the  tissues  as  to  extinguish  their 
vitality,  ordinary  restoration  is  impossible.  This  is  also  true 
when  the  inflammation  is  more  decided  and  persistent.  This 
inflammation  may  extend  throughout  the  tissue.  The  tissues 
may  be  in  a  favorable  condition  for  infection,  yet  the  mouth  and 
blood  vessels  be  free  from  pus  germs.  The  tissues  are  often  in- 
vaded, however,  by  micro-organisms,  resulting  in  suppuration. 
Interstitial  gingivitis,  with  pus  infection  in  and  about  the  alveo- 
lar process,  resembles  suppuration  elsewhere  in  the  body. 

Suppuration  (due  to  pyogenic  cocci)  is  the  usual  termination 
of  infective  inflammation.  Healthy  gum  tissue  is  intolerant  of 
bacteria,  and  will  resist  the  invasion  of  micro-organisms.  When 
inflammation  takes  place,  the  diseased  part  is  unable  to  resist 
them.  Lowered  vitality  of  tissue  is  a  fruitful  source  of  infection 
and  suppuration.  Since,  as  Miller  ^  has  shown,  pus  germs  are 
found  in  almost  every  mouth,  infection  is  a  very  probable  out- 
come of  gingivitis. 

The  organisms  most  frequently  producing  pus  are  the  staphy- 
lococcus pyogenes  aureus,  and  albus.  These  have  a  tendency  to 
accumulate  in  groups.  When  they  collect  at  a  given  point  in  the 
tissue,  suppuration  results.  The  streptococci  (occasionally  pres- 
ent in  the  mouth)  do  not  as  a  rule  produce  local  suppuration,  but 
spread  through  the  tissue  by  way  of  the  lymphatics  and  blood 
vessels,  and  eventually  give  rise  to  abscess.  The  delicate  reticu- 
lum of  the  blood  vessels  found  in  the  Haversian  canals  is  a 


^  Micro-Organisms  of  the  Human  Mouth. 


PYORj^jj(£^  ALVEOLARIS.  287 

convenient  lodging  place  for  swarms  of  bacteria,  owing  to  the 
slowness  of  the  blood  cnrrent  and  the  tortnous  course  of  the 
blood  channels.  When  -  the  circulation  has  been  impeded  or 
arrested  by  an  extravasation  of  blood  or  congestion  of  a  part,  the 
conditions  are  favorable  for  intravascular  infection  if  organisms 
happen  to  be  circulating  in  the  blood  at  the  time.  As  w^e  have 
seen,  micro-organisms  may  from  time  to  time  be  found  in  the  cir- 
culation, particularly  in  individuals  of  feeble  constitution.  The 
anatomic  nature  of  the  part  will  therefore  determine  suppura- 
tion in  certain  localities. 

In  whatever  part  or  tissue  the  change  may  occur,  the  process 
is  the  same.  The  original  structures  disintegrate.  Their  place 
is  taken  by  a  closely  packed  crowd  of  migrated  leucocytes. 
Should  the  cause  continue  to  act,  the  process  culminates  in  the 
formation  of  pus.  The  migrated  cells  cut  off  from  proper  nutri- 
tion by  pressure  are  exposed  to  the  injurious  action  of  micro- 
organisms. The  central  cells  of  the  group  degenerate  from  want 
of  nutrition  or  die  from  direct  action  of  the  irritation.  The 
intercellular  substance  softens,  and  the  liquid  exudate  from  the 
surrounding  parts  mingles  with  the  broken-down  tissue  to  form 
an  abscess. 

As  I  have  shown,  foci  of  infection  and  intense  inflammation, 
to  the  point  of  degeneration  and  liquefaction,  occur  in  almost 
every  locality  within  the  peridental  membrane,  periosteum  and 
what  was  originally  alveolar  process.  These  abscesses  are  just 
as  likely  to  point  upon  the  surface  of  the  gum  as  on  the  inner 
surface  next  to  the  root  of  the  tooth. 

Abscesses  in  and  about  the  alveolar  process  (other  than  those 
due  to  dead  pulps)  are  very  common.  This  is  due  first  to  the 
unstable  condition  of  the  structures,  and  second  to  the  ready 
access  of  pus  germs  through  the  inflamed  gums  and  peridental 
membrane.  Those  most  susceptible  to  infection  are  patients  who 
are  anaemic  and  below  par  in  vitality,  and  whose  gums  have 
become  inflamed  either  from  local  or  constitutional  causes. 
Especially  is  this  the  case  in  those  who  have  osteomalacia  where 
the  gums  have  receded  quite  a  distance  from  the  necks  of  the 
teeth.    Pus  germs  collect  at  the  necks  of  the  teeth,  infect  the  raw 


*  American  Text-Book  of  Surgery. 


288  INTEESTITIAL    GINGIVITIS. 

inflamed  surfaces  of  the  epithelial  layer,  and  entering  the  cir- 
culation are  carried  into  the  deeper  structures.  Intense  inflam- 
mation results.  Abscesses  form,  discharging  their  contents  upon 
the  surface.  Pus  germs  also  enter  the  deeper  structures  through 
exposed  pulps. 

Two  cases  of  interest  in  this  connection  occurred  recently  in 
practice.  An  active  business  man,  fifty-five  years  of  age,  pre- 
sented himself  with  an  abscess  over  the  buccal  roots  of  the  left 
superior  second  molar.  There  were  no  dead  pulps  in  any  of  the 
teeth  upon  that  side  of  the  jaw.  Absorption  of  the  alveolar  proc- 
ess and  contraction  of  the  gums  had  occurred  around  all  the 
teeth.  He  had  been  overworked  and  was  nervously  exhausted. 
Five  years  ago  cataracts  were  removed  from  both  eyes.  He  is 
exceedingly  sensitive  to  pain.  Examination  of  blood  revealed 
slight  anaemia.  On  examination  of  urine,  other  than  a  specific 
gravity  of  1028,  it  was  found  normal.  The  abscess  was  lanced 
and  cavity  cleansed.  It  healed  within  a  week.  Subsequently 
he  returned  with  another  abscess  over  the  root  of  the  right 
superior  central  incisor.  Live  pulps  were  in  all  the  teeth  upon 
this  side  as  far  as  the  second  molar.  Infection,  therefore,  must 
have  occurred  through  the  gum  and  peridental  membrane. 

The  teeth  of  a  lady  forty-six  years  of  age  were  being  put  in 
order ;  after  the  filling  of  a  cavity  she  called  attention  to  a  space 
between  the  second  and  third  superior  right  molars,  and  stated 
food  lodged  at  that  point,  causing  pain  and  bleeding.  The  space 
was  cleansed  with  an  excavator  and  the  cavity  syringed  with 
warm  water  and  then  explored.  Absorption  of  the  gums  and 
alveolar  process  had  extended  one-half  the  length  of  the  buccal 
root.  Applications  of  iodoglycerole  were  made  to  reduce  the  in- 
flammation. The  patient  was  dismissed  with  an  appointment  for 
further  treatment.  She  returned  at  the  appointed  time  with  an 
abscess  over  the  palatine  root  as  large  as  the  thumb.  The  lady 
had  had  acute  pain  from  the  time  she  left  the  office  until  her 
return.  The  parts  had  become  infected  with  pus  germs  through 
the  peridental  membrane.  The  pus  was  collected  in  a  tin  tea 
spoon,  from  which  cultures  were  obtained  and  glass  slabs 
smeared  for  microscopic  examination.     The  pus  was  examined 


PVORRHCEA  ALYEOLARIS.  289 

by  George  T.  Carpenter  for  calcic  deposits ;  the  usual  aseptic 
precautions  having  been  taken. 

Many  dentists,  ignoring  the  laws  of  pathology,  insist  that 
intense  inflammation  in  remote  parts  of  the  alveolar  process  is 
not  due  to  toxins  and  irritations  but  is  the  result  of  gouty  de- 
posits. The  utter  lack  of  foundation  for  this  theory  must  be 
apparent  on  the  slightest  study  of  pathology. 

Ulceration  is  always  located  upon  the  surface  of  a  tissue. 
When  ulceration  occurs  fi'om  contact  irritation  of  the  gum  mar- 
gin or  by  mechanical  or  chemical  means,  congestion  and  oedema 
result,  thickening  of  the  epithelial  layer  and  increased  growth  of 
cells.  The  sub-epithelial  tissue  becomes  inflamed.  The  process 
is  not  unlike  that  of  the  formation  of  an  abscess,  since  the 
infected  tissue  resembles  part  of  an  abscess  wall.  In  slowness  of 
progress  only  does  ulceration  differ  from  acute  inflammation. 

Such  is  the  condition  of  the  peridental  membrane.  When 
simple  gingivitis  becomes  chronic,  the  inflammation  extends  to 
the  surface  of  the  peridental  membrane.  This  is  situated  at  the 
lower  extremity  of  a  cul-de-sac,  formed  by  the  gum  on  the  one 
hand  and  the  tooth  on  the  other.  This  cavity  is  filled  with  for- 
eign material  in  which  decomposition  continually  occurs.  The 
tissues  are  thereby  constantly  irritated.  Necrosis  occurs  at  the 
surface.  In  the  deeper  tissues  that  have  l)ecome  inflamed  pus 
cells  also  are  found.  These  not  only  arise  from  the  normal  blood 
vessels  in  the  vicinity,  but  also  from  the  granulation  tissue.  The 
causes  of  peridental  membrane  ulceration  are  disturbances  of 
nutrition,  endarteritis  obliterans  (a  disease  of  the  blood  vessels 
due  to  constitutional  diseases,  such  as  syphilis,  scurvy,  tubercu- 
losis, uric  acid  and  other  blood  poisons)  and  starvation  of  tissue, 
feeble  circulation  (as  in  anaemia)  and  inflammation.  If  the 
ulcerated  surface  be  examined  under  the  microscope,  a  general 
thickening  of  the  tissues  will  be  seen.  In  the  papillary  layer  de- 
posits of  blood  pigment  occur.  The  surface  is  covered  with 
granulation  tissue.  The  tissue  may,  in  part,  resemble  the  type 
of  healthy  granulation.  It  is  composed  of  round  cells  closely 
packed  together  and  supplied  with  rich  capillary  network.  Co- 
agulation necrosis  from  breaking  down  of  granulation  tissue 
may  be  present.  ' 


290  TXTERSni'l'IAL   OINCIVTTIR. 

Pus  pockets  start  with  any  local  iri'itation  which  sets  up  in- 
flammation (interstitia]  gingivitis)  at  tlic  gingival  hordci-  of  the 
gnms.  Tiie  inflannnation  spreads  to  the  blood  vessels  of  the  peri- 
dental membrane  and  alveolar  process.  Round  cell  infiltration 
I'apidly  takes  f)lcice  and  the  bone  becomes  destroyed,  beginning 
at  the  gum  margin  or  in  the  peridental  membrane  and  extending 
toward  the  apical  end  of  the  root  or  to  the  mucous  membrane 
of  the  mouth.  The  irritation  which  is  confined  to  narrower  areas 
may  ])ecome  so  intense  and  the  inflammatory  exudate  increase 
so  rapidly  that  nothing  remains  except  the  fibrous  tissue  which 
originally  held  the  bone  cells,  or  the  tissue  becomes  entirely  lost. 
The  leucocytes  now  collect  in  large  numbers  within  the  fibrous 
tissue  and  liipiefaction  and  disintegration  of  tissue  results,  form- 
ing y)us   pockets. 


M 


Fig.  92. — TiiicKEXiNG  of  the  Peridental  Membkaxe  and  Trabeculae   (OriginaiO. 

Alvcohir  abscess  is  a  term  applied  to  an  accumulation  of  pus 
at  the  apical  end  of  the  root  of  a  tooth  due  to  death  of  the  dental 
pulp  and  other  irritations.  When  death  of  the  pulp  occurs,  de- 
composition takes  place  and  gases  form  in  the  pulp  chaml)er, 
Tlie  gases  expand  and  an  outlet  is  acfiuired  through  the  end  of 
the  root  of  the  tooth.  Tlu^se  gases  and  other  irritations  set  up 
inflammation  in  the  peridental  meml)rane,  pi'oducing  an  nlvcohnr 
abscess. 


PYOERHCEA   ALVEOLARIS. 


291 


The  other  irritations  may  be  foreign  substances  forced 
through  the  end  of  the  root  or  poisons  in  the  organism  passing 
through  the  blood  stream.  These  irritants  set  up  interstitial  gin- 
givitis in  the  arteries  running  through  the  peridental  membrane 
and  also  into  the  alveolar  process  and  maxillary  bone.     Inter- 


FiG.  93. — Shows  the  Eemoval  of  the  Outer  Plate  or  Bone  and   Exposing  the 
EooT  OF  the  Tooth  and  the  Alveolar  Abscess  (Original). 

stitial  gingivitis  becomes  quite  diffused.  Bone  absorption 
(halisteresis  and  Volkmann's  canal  absorption)  immediately 
takes  place  and  a  considerable  area  of  bone  about  the  end  of  the 


Fig.  94. — Tooth  With  Abscess  Attached  Removed  From  the  Bone  (Original). 

root  is  destroyed,  leaving  the  fibrous  tissue  (formerly  the  tra- 
beculae  of  the  bone)  in  a  thickened  condition  tightly  attached  to 
the  end  of  the  root  (Fig.  92). 


292 


INTERSTITIAL    GINGIVITIS. 


As  absorption  proceeds,  the  lime  salts  in  the  inflamed  area 
are  thus  destroy  ed  and  the  fibrous  tissue  or  trabecule  become 
organized  (Fig.  93).  If  the  tooth  is  extracted  before  liquefaction 
occurs,  the  fibrous  mass  may  be  removed  in  situ  (Fig.  94).     A 


.M 


Fig.  95. — Microscopic  Illustration  of  the  End  of  the  Root  of  the  Tooth. 
A,  Cemeiitum.       B,  C,  Abscess  attached.  D,  Two  Points  of  Liquefaction.      (Original). 

low  microscopic  section  of  this  picture  shows  the  end  of  the  root 
with  fibrous  mass  attached  and  degeneration  and  liquefaction 
of  tissue  just  commencing  at  two  points  near  the  center  of  the 
mass    (Fig.   95).     A   higher  magnification   showing   round-cell 


Tv-.^ 


r 


^K%kt^ 


Fig.  96. — Microscopic  Alveolar  Ap,sce.s.s  Sac  (Original). 

infiltration  and  breaking  down  of  tissue,  liquefying  into  pus  is 
seen  in  Fig.  96.  The  pyogenic  membrane  forming  the  abscess 
walls  is  well  shown. 


PYOERHCEA    ALVEOLARIS.  293 

The  cause  of  the  irritation  producing  interstitial  gingivitis 
may  be  so  severe  and  active  that  not  only  is  there  destruction 


Fig.  97. — Tooth  Showing  Formation  and  Destruction  of  Abscess  With  Carious 
Cavity  (Original).  The  Irritation  Which  Caused  the  Inflammation  and 
Formed  the  Abscess  Was  so  Great  as  to  Cause  Destruction  of  the  Sac. 

of  bone,  but  also  of  the  trabeculae.     Under  such  conditions  the 
root  of  the  tooth  is  seen  denuded  of  surrounding  tissue  (Fig.  97). 


Fig.  98. — Four  Abscesses  in  the  Peridental  Membrane  and  Trabeculae  in  a 
Diabetic  Man   (Original). 

In  Fig.  9(S  four  pericemental  abscesses  are  seen  along  the 
side  of  the  root  of  the  tooth.    These  are  due  to  the  lowered  vital- 


294  INTERSTITIAL    GINGIVITIS. 

ity  of  the  individual  and  infection  after  interstitial  gingivitis 
has  become  quite  extensive.  These  abscesses  are  very  common. 
The  tissues  about  the  roots  of  the  teeth  become  inflamed,  infec- 
tion takes  place,  abscesses  form  and  discharge.  The  fistula  heals 
without  pain  or  inconvenience  to  the  patient. 

In  summing  up  this  chapter  on  pyorrhoea  alveolaris,  the 
reader  must  not  lose  sight  of  the  fact  that  pus  infection  in  no 
way  influences  the  absorption  of  the  alveolar  process  and  exfolia- 
tion of  the  teeth.  It  is  always  the  primary  inflammatory  stage 
that  causes  the  absorption  and  the  pus  infection  is  only 
incidental. 


CHAPTER  XXVII. 

CONSTITUTIONAL  EFFECTS  OF  PYORRHOEA  ALVEOLARIS. 

Every  person  with  pyorrhoea  alveolaris  has  pus  germs  in  the 
mouth  which  are  constantly  being  carried  into  the  fauces,  stom- 
ach and  throughout  the  ahmentary  canal.  That  these  pus  germs 
under  certain  conditions  are  destroyed  in  the  stomach  by  the 
gastric  juices,  to  my  knowledge,  has  never  been  demonstrated. 
A  factor  unfavorable  to  this  theory  is  the  non-presence  of  the 
hydrochloric  acid  in  the  stomach  except  when  food  be  present, 
whereas  the  saliva,  laden  with  pus  germs,  is  continually  passing 
into  the  stomach  and  the  germs  must,  without  doubt,  find  their 
way  into  other  organs,  causing  grave  constitutional  states  which, 
in  many  instances,  finally  result  in  death. 

The  degree  of  organic  infection  varies  in  intensity.  The 
germs  passing  into  the  stomach  with  the  food  are,  on  account  of 
the  presence  of  the  hydrochloric  acid,  changed  in  character,  while 
those  passing  into  the  stomach  other  than  during  digestion,  are 
more  virulent  and  act  with  greater  intensity  upon  the  intestine 
and  organ  walls,  since  they  produce  a  catarrhal  condition,  first 
acute  which  later  becomes  chronic.  It  has  been  shown  repeat- 
edly that  many  stomach  troubles  have  improved  or  recovery  has 
been  complete  when  the  mouth  has  been  put  into  an  aseptic 
condition. 

The  influence  of  the  stage  of  interstitial  gingivitis  known  as 
pyorrhoea  alveolaris  on  the  system  has  been  discussed  by  John 
Fitzgerald,^  who  points  out  that  pyorrhoea  alveolaris  may  act 
in  three  different  ways  in  the  causation  of  systemic  disease. 
First,  the  pus  with  its  multitude  of  putrefactive  organisms  and 
decayed  food  remnants  from  the  pus  pockets  is  swallowed  and 
either  acts  locally  upon  the  stomach  wall  or  sets  up  fermentation 
of  the  stomach  contents;  second,  the  toxins  generated  in  the 
mouth  may  be  absorbed  by  the  mucous  membrane  of  the  mouth 
or  stomach  and  thus  pass  into  the  general  circulation;  third,  the 


^  Clinical  Journal,  March  6,  1899. 


296  INTERSTITIAL    GINGIVITIS. 

local  conditions  of  the  mouth  may  favor  the  growth  of  patho- 
genic organisms  and  thus  render  the  patient  more  liable  to  cer- 
tain infectious  disorders,  noticeably  influenza.  The  power  of 
pyorrhoea  alveolaris  to  produce  aggravation  of  existing  gastric 
trouble  reaches  its  maximum  in  cases  where  there  is  retention 
of  food  residue.  This  happens  when  the  muscular  walls  of  the 
stomach  are  in  a  state  of  atony  and  also  when  there  is  some 
pyloric  obstruction  which  prevents  the  organ  emptying  itself. 
In  both  these  conditions  stomach  dilatation  is  eventually  pro- 
duced, with  the  result  that  the  stomach  is  never  completely  emp- 
tied. The  first  condition  is  a  very  frequent  concomitant  of 
neurasthenia  and  allied  states.  It  is  easy  to  see  how  pyorrhoea 
can  at  once  be  predisposed  to  by  neurasthenic  states  and  at  the 
same  time  increase  the  neurasthenia  by  causing  gastric  trouble 
through  its  interference  with  gastro-intestinal  digestion  under 
the  conditions  mentioned. 

Fitzgerald  points  out  that  the  bacillus  coli  communis  is  a 
constant  inhabitant  of  the  oral  cavity,  and,  as  a  rule,  seemingly 
harmless.  Under  the  influences  of  a  culture  medium,  such  as 
would  be  furnished  by  pyorrhoea  or  an  inflammatory  state  of  the 
gum,  this  bacteria  might,  as  elsewhere  in  the  mucous  membrane, 
acquire  sufficient  virulence  to  produce  serious  disturbances  of 
the  system,  such  as  colitis,  dysentery  and  cholera  nostras. 

Herschell  -  is  of  the  opinion  that  many  of  the  chronic  indi- 
gestions are  due  to  continual  absorption  of  pus  into  the  system 
from  pyorrhoea  alveolaris.  In  these  cases  he  remarks  there 
should  be  other  evidences  of  the  absorption  of  toxins,  such  as 
X)igment  spots,  urticaria,  etc. 

Within  the  past  few  years  medical  thought  has  centered 
around  the  mouth  and  its  infection  as  a  possible  cause  of  many 
diseases  even  far  removed  from  it.  The  many  germs  of  more  or 
less  virulence  which  have  already  been  isolated  in  the  mouth 
must  of  necessity  affect  mucous  surfaces  in  other  parts  of  the 
body.  Medical  researches  have  shown  that  diseases  like  per- 
nicious anaemia,  arthritis  deformans,  all  rheumatic  states,  bac- 
terial endocarditis,  headaches,  many  other  obscure  conditions, 


Indigestion,  1895. 


CONSTITUTIONAL   EFFECTS    OF    PYORRHCEA.  297 

etc.,  yield  more  readily  to  treatment  when  the  mouth  has  been 
put  into  an  aseptic  condition.  Every  dentist  has  experienced  the 
fact  that  when  a  poorly  nourished  patient  has  had  loose  teeth 
extracted,  artificial  ones  substituted  and  the  mouth  entirely 
cleaned  up,  there  will  be  increase  in  weight  and  better  health. 
American  and  foreign  journals  are  full  of  experiences  of  like 
nature. 

Many  writers  who  believe  in  the  theory  of  the  conveyance  of 
j)us  germs  throughout  the  body  have  recorded  histories  of  pa- 
tients who  are  believed  to  have  been  thus  infected.  Some  of 
these  are  interesting  and  here  mentioned  to  show  what  serious 
constitutional  conditions  take  place  from  an  unhygienic  condi- 
tion of  the  mouth  and  teeth. 

There  are  many  affections  of  the  tonsils,  neck  glands,  etc., 
directly  traceable  to  the  sei)tic  condition  of  the  mouth  and  teeth. 
Especially  is  this  true  of  school  children.  Stewart  ^  reports  231 
cases  of  tonsil  enlargement  in  which  135  had  a  caried  condition 
principally  of  the  lower  molars  on  the  enlarged  tonsil  side;  67 
had  caries  and  an  unhj^gienic  mouth ;  16  had  no  septic  condition 
of  the  mouth  and  15  had  caries  and  a  septic  state  on  the  opposite 
side.  He  also  mentions  cases  of  laryngitis  which  yielded  to 
treatment  after  putting  the  mouth  in  an  aseptic  state. 

It  has  long  been  known  that  nearly  all  glandular  conditions 
are  dependent  upon  bacterial  infection  of  more  or  less  virulency. 
Many  cases  of  gland  infection  have  been  shown  to  be  directly 
due  to  a  sej^tic  condition  of  the  mouth.  A  case  coming  under  the 
author's  notice  was  that  of  a  twenty- three-year-old  man  whose 
original  mouth  condition  of  pyorrhoea  alveolaris  was  augmented 
by  a  local  spirrilla  infection.  After  being  under  treatment  for 
some  weeks  with  no  recovery  results,  he  was  referred  to  me.  I 
found  the  gums,  peridental  membrane  and  alveolar  process  in  a 
severe  inflammatory  state  with  pus  oozing  from  the  tooth 
sockets.  The  neck  glands  were  enlarged  on  both  sides  and  tender 
to  touch.  After  the  mouth  was  put  in  an  aseptic  state,  the  glands 
became  their  noimal  size  and  the  tenderness  disappeared. 


'Stewart,  C.  J.    Oral  Sepsis  in  its  Connection  With  Throat  Diseases.     The  Lancet, 
June  25,  1902.  p.  1882! 

*  Hunter.  W.     The  Lancet,  1900,  1904. 


298  INTERSTITIAL    GINGIVITIS. 

Hunter  *  reports  a  case  of  gastritis  which  he  claims  is  directly 
due  to  infection  from  the  mouth.  A  sixty-two-year-old  woman 
was  suffering-  with  subacute  gastritis.  There  was  severe  pain 
and  intermittent  sickness,  so  much  so  that  morphia  was  often 
resorted  to.  The  illness  had  been  of  eight  months'  duration 
coupled  with  loss  of  weight  and  great  weakness.  Examination 
for  cancer  of  the  stomach,  abdomen,  rectum  or  uterus  revealed 
nothing.  There  was  continually  a  bitter  taste  in  the  mouth, 
nausea  and  loss  of  appetite.  Examination  of  the  vomit  found  it 
filled  with  streptococci,  staphylococci  and  a  few  bacilli.  There 
were  three  roots  of  teeth  remaining  in  the  mouth  from  whose 
sockets  there  was  a  constant  flow  of  pus.  With  the  extraction 
of  the  roots  the  stomach  condition  was  benefited. 

It  has  been  a  much  discussed  question  among  physicians  as 
to  w^hether  gastric  ulcers  are  not  directly  due  to  a  septic  condi- 
tion of  the  mouth,  but  convincing  proof  has  not  been  evidenced 
since  gastric  ulcers  are  known  to  occur  in  persons  with  healthy 
mouths.  In  the  chronic  ulcer  type,  however,  an  unclean  mouth 
with  pus  coming  from  the  tooth  sockets  is  the  rule. 

Dr.  Frank  Billings,  in  a  paper  on  "Chronic  Focal  Infections 
and  Their  Etiologic  Relation  to  Arthritis  and  Nephritis"^ 
speaking  of  the  site  of  local  infection,  mentions  "the  faucial 
tonsils,  abscesses  of  the  gums  and  alveolar  sockets,  pyorrhoea 
alveolaris  and  septic  types  of  gingivitis  may  also  cause  systemic 
diseases  of  various  types.  The  systemic  results  of  focal  infec- 
tion are:  1.  Chronic  arthritis  is  one  of  the  most  common  re- 
sults. 2.  Nephritis,  both  acute  and  chronic.  3.  Cardiovascular 
degenerations.  4.  Chronic  neuritis  and  myalgia  (myositis)." 
He  says  further,  "The  studies  and  experiments  embodied  in  this 
paper  are  limited  to  the  arthritides  and  to  subacute  and  paren- 
chymatous nephritis.  Of  these,  chronic  deforming  arthritis,  com- 
monly known  as  arthritis  deformans,  and  chronic  osteo-arthritis 
of  hypertrophic  or  atrophic  type,  comprise  the  majority  of  the 
studies.  Next  to  the  arthritides  the  largest  number  of  cases  com- 
prises subacute  parenchymatous  nephritis  and  chronic  paren- 
chymatous nephritis.  The  work  has  been  done  on  private  and 
clinic  patients  in  the  Presbyterian  Hospital.    The  bacteriologic 


» The  Illinois  Medical  Journal,  March,  1912. 


CONSTITUTIONAL   EFFECTS    OF   PYOEEHCEA.  299 

and  histologic  studies  and  the  animal  experiments  have  been  car- 
ried on  by  Dr.  D.  J.  Davis  and  by  Dr.  Homer  K.  Nicoll." 

Ten  cases  of  arthritis  and  six  cases  of  subacute  and  chronic 
parenchymatous  nephritis  are  described.  Among  this  number 
case  Number  III  is  worthy  of  special  mention  here. 

Case  3. — Mrs.  E.  W.,  aged  50  years.  I-para.  Osteoarthritis 
chronica,  mixed  type.  Admitted  to  the  Presbyterian  Hospital 
Oct.  16,  1909.  For  two  years  there  had  been  swelling,  tender- 
ness, pain  upon  motion  and  deformity  of  many  of  the  joints  of 
extremities.  Began  in  feet  and  hands  and  extended  to  larger 
joints  and  finally  involved  cervical  spine.  The  condition  was 
progressive.  There  was  malnutrition,  loss  of  weight  from  160 
to  120  pounds.  For  years  the  patient  had  been  subject  to  attacks 
of  acute  tonsilitis.  She  had  also  suffered  for  years  from  pyor- 
rhoea alveolaris. 

Examination :  Poorly  nourished,  very  nervous  and  irritable. 
Mouth  badly  infected,  many  stumps  of  carious  teeth,  some  of 
them  loose  in  the  sockets,  gums  retracted  and  infected,  tonsils 
large,  rough,  adherent  to  pillars  of  fauces  and  crypts  infected. 
Breath  offensive.  Heart,  lungs,  abdominal  organs  and  pelvic 
organs  normal.  There  was  swelling  with  some  deformity  of 
both  ankles,  right  metatarsophalangeal,  both  knees,  right  middle 
and  left  fingers,  the  wrists,  and  elbows.  Some  contraction  of 
hamstring  muscles  prevented  complete  extension  of  legs.  Both 
bleep  tendons  of  the  arms  contracted  which  prevented  extension 
of  the  forearm.  Twenty-four  hours'  collection  of  urine  was  nor- 
mal in  amount  and  specific  gravity  and  contained  a  few  hyalin 
casts.  Blood :  Hemoglobin,  90  per  cent ;  reds,  4,600,000 ;  whites, 
13,400.  On  Oct.  18,  1909,  both  f  aucial  tonsils  were  enucleated  by 
Dr.  George  E.  Shambaugh  and  one  week  later  the  roots  of  cari- 
ous teeth  were  removed  by  Dr.  Frederick  Moorhead.  From  the 
cut  surface  of  the  tonsillar  tissues  a  pure  culture  of  streptococcus 
was  obtained.  A  rabbit  inoculated  A\itli  a  culture  suffered  from 
acute  multiple  arthritis  and  died  in  a  few  days.  The  strepto- 
coccus was  regained  from  the  infected  joints  and  from  the 
heart's  blood.  The  patient  was  permitted  to  return  to  her  home 
too  soon  and  did  not  fully  carry  out  directions  as  to  rest  treat- 
ment.    Some  time  elapsed  before  the  alveolar  processes  were 


300  INTERSTITIAL    GINGIVITIS. 

absorbed  and  the  mouth  remained  sore.  On  April  3,  1910,  she 
returned  to  the  hospital,  where  rest  treatment  was  instituted 
with  resulting  marked  improvement.  The  patient  gained  in 
weight  from  129  to  140  pounds.  After  the  return  home  fre- 
quent communications  by  letter  with  the  patient  and  her  physi- 
cian have  shown  that  the  progress  of  the  disease  has  entirely 
stopped.  Some  of  the  deformities  were  so  great  that  one  could 
not  expect  entire  anatomical  restoration.  The  last  communica- 
tion is  dated  December,  1911,  in  which  the  patient  says  that  the 
strength  of  her  ui3per  extremities  and  spine  is  entirely  normal. 
There  is  some  fatigue  in  the  lower  extremities  after  attempting 
to  walk  for  any  great  distance,  but  there  is  a  continued  improve- 
ment even  in  this  respect. 

All  the  cases  cited  in  this  article  are  of  unusual  interest  be- 
cause they  are  based  upon  researches  and  actually  demonstrate 
the  source  of  infection  and  the  results  of  such  infection  upon 
animals. 

Osier  says  of  the  twenty  cases  of  pernicious  anaemia  which 
he  had  under  observation  in  1909,  pyorrhoea  alveolaris  was  pres- 
ent in  more  than  half.  Certain  types  of  nephritis  are  also  be- 
lieved to  be  due  to  oral  infection.*' 

Zilz  '  reports  four  cases  of  cysts  at  the  roots  of  teeth  in  which 
bacteriologic  investigations  revealed  the  presence  of  Much's 
granula,  which  he  defines  as  the  non-acid-fast  form  of  the 
tuberculosis  germ.  The  findings  are  profusely  illustrated  and 
the  questions  discussed  are  "why  it  is  so  difficult  to  detect  acid- 
fast,  Gram-staining  bacilli  in  the  gangrenous  pulpa,"  and  ''why 
primary  tuberculosis  starting  in  carious  teeth  is  not  of  more 
common  occurrence."  He  regards  Much's  granula  as  merely 
ordinary  acid-fast  tubercle  bacilli  which  have  lost  their  acid-fast 
properties ;  hence  the  organic  fluids  are  able  to  disintegrate  them 
and  the  vital  centers,  the  granula,  escape  into  surrounding  me- 
dium. When  conditions  become  more  favorable  to  the  bacilli, 
they  may  become  impregnated  again  with  acid-fast  substance 
and  the  acid-fast  form  thus  develop  again,  which  in  turn  may 
break  up  anew  into  granula.    His  plates  show  the  process  dis- 


•  Practice  of  Medicine,  p.  440. 

''  Beitrage  znr  Klinik  der  Tuberkulose,  Wiirzburg,  Vol.  XXII,  No.  2,  pp.  97-264. 


CONSTITUTIONAL   EFFECTS    OF   PYORRHOEA.  301 

tinctly,  the  granula  causing  no  tuberculous  changes  in  the  dental 
cyst.  The  bacilli  probably  found  their  way  through  the  blood 
into  the  cyst  and  while  there  remained  latent  but  regained  their 
virulence  when  conveyed  farther  to  lymph-nodes  or  lungs.  In- 
oculation of  animals  with  the  granuUi  always  gave  positive 
results. 

W.  Hunter  ®  has  repeatedly  called  the  attention  of  the  pro- 
fession to  the  close  relationship  existing  between  the  mouth 
infection  and  the  various  forms  of  anaemia,  particularly  the  per- 
nicious type.  He  contends  that  the  pus  taken  into  the  stomach 
produces  an  unhealthy  state  of  that  organ  and  also  the  intes- 
tines, thereby  favoring  the  destruction  of  the  red  blood  cells. 

In  all  forms  of  arthritis  there  is  an  association  in  the  condi- 
tion of  the  mouth.  The  disease  stamps  itself  indelibly  upon  the 
alveolar  process.  There  is  gum  recession  and  absorption  of  the 
alveolar  process  of  more  or  less  intensity  and  pus  infection. 

A  case  referred  to  the  author  for  treatment  of  the  mouth  is 
of  more  than  passing  interest.  The  patient,  a  twenty-seven- 
year-old  woman,  unmarried,  had  been  a  sufferer  from  arthritis 
deformans  for  many  years.  For  ten  years  previous  to  her  com- 
ing to  me  she  had  been  unable  to  leave  her  home  except  when 
carried.  The  entire  osseous  system  was  involved,  but  more 
especially  the  extremities.  The  hands  had  become  so  malformed 
and  stiff  that  she  was  unable  to  pick  up  or  hold  anything.  The 
mouth  was  in  frightful  shape.  There  were  loose  teeth  with  pyor- 
rhoea alveolaris,  absorption  of  the  gums  and  alveolar  process,  a 
number  of  large  cavities,  tartar  and  calcic  deposits.  After  the 
loose  teeth  had  been  extracted,  the  tartar  and  calcic  deposits 
removed,  the  cavities  filled,  an  artificial  denture  inserted  and 
the  pyorrhoea  alveolaris  treated,  the  constitutional  condition 
commenced  to  improve.  At  the  end  of  three  months  she  could 
walk  with  the  aid  of  crutches,  in  six  months  with  only  the  use  of 
a  cane,  and  at  the  end  of  a  year  had  no  use  for  either.  The  stiff- 
ness in  the  hands  disappeared  to  such  a  degree  that  she  could 
use  them.  She  has  now  recovered  to  such  an  extent  that  she  is 
able  to  assist  in  the  housework. 


8  The  Lancot.  1900,  1904. 


302  INTEESTITIAL    GINGIVITIS. 

Dr.  Kenneth  Goadby,''  of  London,  England,  reports  four  in- 
teresting cases  of  arthritis  which  are  worthy  of  consideration  at 
this  time.    They  are  as  follows : 

Case  1. — A  girl,  aged  tw^enty-two,  was  attacked  somewhat 
suddenly  by  swelling  of  the  hands  and  feet  and  fever  lasting 
tw^o  or  three  weeks.  With  the  subsidence  of  the  fever  the  joints 
did  not  return  to  their  normal  size  but  remained  painful  and 
stiff ;  walking  was  almost  impossible.  The  affection  was  bilateral 
and  the  swelling  was  evidently  peri-articular,  and  to  a  limited 
extent  affected  the  synovia  of  the  joints,  but  no  fluid  was  dis- 
covered. Treatment  at  Bath  and  a  long  course  of  salicylates 
produced  little  improvement.  There  was  no  family  history  of 
rheumatism  or  of  gonorrheal  infection  and  no  septic  focus  was 
thought  to  exist.  On  examination  of  the  mouth,  the  right  upper 
central  incisor  was  missing,  the  teeth  and  gums  were  apparently 
quite  normal.  A  closer  examination  revealed  a  small  sinus  lead- 
ing up  to  the  root  of  the  missing  central  incisor  and  a  film  made 
from  the  sinus  showed  a  large  number  of  pus  cells  loaded  with 
organisms.  Cultures  were  made  and  an  organism  was  isolated 
in  practically  pure  culture ;  the  blood  tested  against  this  organ- 
ism gave  a  very  low^  opsonic  as  well  as  a  low^  phagocytic  index. 
A  vaccine  was  prepared  and  injections  given,  commencing  with 
ten  million  dead  bacteria.  After  four  injections  the  sinus  was 
opened  under  a  general  anesthetic  and  was  found  to  lead  into  a 
cavity  in  the  bone  about  the  size  of  a  small  hazelnut.  This  was 
cleared  out  ^vith  a  sharp  spoon  and  the  lateral  incisor  also  was 
removed,  the  cavity  extending  under  its  root  and  invading  the 
periosteum  of  the  tooth.  The  improvement  of  the  joints  which 
had  commenced  with  the  inoculations  received  a  slight  tem- 
porary setback  as  the  immediate  result  of  the  operation,  but 
improvement  soon  recommenced  with  continued  vaccine  therapy 
and  the  patient  has  steadily  improved  and  is  almost  well. 

The  second  case  is  that  of  a  man  of  thirty-eight  years.  He 
was  suffering  from  acute  pain  and  swelling  in  both  knees  and 
both  feet,  ulnar  deflection  of  both  hands  and  acute  pain  and 
swelling  on  the  dorsal  aspects,  fluid  and  deformity  of  the  left 
elbow  joint  and  of  the  left  shoulder  joint,  anaemia  and  neuras- 


The  Practitioner  (London),  January,  1912. 


CONSTITUTIONAL  EFFECTS  OF  PYOERHCEA.  303 

tlieiiia,  partly  owing  to  the  constant  pain  and  partly  toxic.  I 
may  note  in  passing  that  secondary  septic  neurasthenia  is  com- 
mon in  cases  of  oral  infection,  probably  due  to  the  long-continued 
infection  with  small  doses  of  bacterial  toxins.  The  patient  had 
been  under  all  sorts  of  treatment,  residence  at  Continental  and 
English  Spas,  had  been  to  the  Canary  Islands,  had  taken  vast 
quantities  of  iodid  of  potassium,  had  had  massage,  electric  baths, 
ionisation  and  ''Christian  Science"  and  all  with  no  avail. 

His  mouth  was  a  veritable  gold  mine ;  he  had  two  bridges,  two 
in  the  upper,  two  in  the  lower  jaw,  and  four  gold  crow^ns  in  addi- 
tion to  the  bridges;  pus  was  welling  up  from  his  gums  in  all 
directions.  The  builder  of  the  bridges  told  him  he  could  do  noth- 
ing for  him  as  he  had  rheumatism  in  his  gums.  He  was  treated 
by  the  removal  of  all  the  crowns  and  bridges  and  by  vaccines 
made  from  his  two  organisms.  He  made  a  slow  but  steady  recov- 
ery and  is  now  enabled  to  resume  his  ordinary  avocation  which 
he  had  been  obliged  to  give  up  for  three  years  previous.  Unfor- 
tunately the  right  knee-joint  is  partially  disabled  owing  to 
exostosis. 

The  third  case,  a  man  aged  forty,  in  March,  1908,  had  a  sud- 
den attack  of  pain  behind  the  left  ear,  progressive  stiffness  and 
muscular  rheumatism  and  stiffness  of  the  right  shoulder  and 
right  hip  joints.  Ten  days  later,  rigor,  temperature  102°  F.  and 
evening  temperature  of  100"  F.  for  two  or  three  weeks  which 
gradually  subsided.  In  the  following  spring  another  acute  attack 
with  fever,  pains  in  the  head  and  neck,  swelling  of  sterno-mastoid 
sheath  and  stiff  neck,  lasting  five  weeks.  An  X-ray  photograph 
of  the  chest  was  taken  and  it  was  thought  the  case  was  one  of 
early  tuberculosis ;  the  patient  was  sent  to  a  sanatorium  where 
he  derived  no  benefit.  He  was  in  constant  pain,  unable  to  move 
his  head,  and  had  constant  attacks  of  fever  at  night,  the  tem- 
perature running  up  to  100°  F.  and  falling  to  subnormal  in  the 
morning.  He  became  wasted,  losing  more  than  a  stone  in  weight, 
was  greatly  depressed  mentally  and  had  to  give  up  his  work. 
On  examination  in  October,  1909,  considerable  thickening  was 
found  in  the  left  shoulder  joint  and  right  knee  joint.  The  left 
sterno-mastoid  was  thickened  in  the  region  of  the  rectus,  capitis 
posticus  and  complexus,  and  thickened  tender  areas  along  the 


304  INTERSTITIAL    GINGIVITIS. 

spine  process  of  the  cervical  and  dorsal  vertebrae.  Hyperes- 
thesia over  all  cranial  nerves.  The  patient  could  walk  only  with 
difficulty. 

The  molar  teeth  had  been  lost  on  both  sides  in  both  jaws. 
The  patient  resented  any  suggestion  that  his  mouth  was  at  fault, 
as  he  had  recently  seen  his  dentist  who  pronounced  his  gums  and 
teeth  quite  sound,  and  the  gums  appeared  normal  in  color. 
Careful  examination  with  a  fine  platinum  probe  brought  to  light 
several  deficiencies  between  the  remaining  teeth  and  passing 
down  to  bare  bone,  and  microscopically  pus  was  demonstrated. 
A  vaccine  was  therefore  prepared  and  inoculations  were  per- 
formed. The  patient  made  an  uninterrupted  recovery,  the  inoc- 
ulations were  discontinued  and  a  slight  relapse  took  place.  The 
vaccine  was  therefore  continued  for  a  further  six  months.  The 
patient  made  a  complete  recovery. 

In  the  fourth  case,  a  w^oman  aged  forty-two,  there  was  a 
severe  general  infection  of  the  mouth.  All  the  teeth  were  loose 
and  copious  discharges  of  pus  came  from  all  sockets.  There  had 
been  chronic  progressive  arthritis  for  the  last  four  years  asso- 
ciated with  occasional  acute  exacerbations,  constant  pain  in  both 
knee  joints  which  were  swollen  and  thickened,  especially  the  ex- 
ternal and  lower  portions  of  the  capsule;  creaking  was  well 
marked  in  the  knees  and  shoulders,  with  ulnar  deflection  of  the 
right  hand.  All  teeth  were  removed  and  considerable  improve- 
ment took  place.  Six  months  after  removal  of  teeth  pain  re- 
curred in  the  right  knee  and  in  the  shoulders  but  passed  off.  A 
year  later,  eighteen  months  after  removal  of  teeth,  the  pain  and 
stiffness  of  the  knees  again  recurred  together  with  fusiform 
swellings  and  local  vasomotor  disturbances  of  the  fingers.  On 
examination  the  gums  were  found  quite  healed;  there  was  no 
inflammation,  but  small  patches  of  thickening  were  seen  along 
the  outer  surfaces  of  the  alveolar  process.  A  puncture  was  made 
into  these  and  a  pure  culture  of  the  streptobacillus  malae  was 
found.  Vaccine  therapy  was  instituted  and  the  rheumatoid  symp- 
toms rapidly  disappeared  and  two  years  later  no  recurrence 
had  taken  place. 
'  Every  specialist  has  noted  the  marked  improvement  in  his 
patients,  some  of  whom  were  suffering  with  obscure  ailments, 


CONSTITUTIONAL  EFFECTS  OF  PYORRHCEA.  305 

after  liaving  loose  teeth  removed,  pyorrhoea  alveolaris  treated 
and  cured,  gums  and  mouth  placed  in  an  hygienic  condition, 
artificial  teeth  inserted  to  fill  vacant  spaces,  and  many  expe- 
riences could  be  recorded. 

Gilmer  ^°  reports  three  interesting  cases.  He  says,  ''Some 
years  ago,  a  man,  a  little  beyond  middle  life,  consulted  me  rela- 
tive to  a  trivial  dental  lesion.  On  making  a  careful  examina- 
tion of  the  entire  oral  cavity,  I  found  several  small  sinuses  dis- 
charging pus  above  the  bicuspid  teeth  on  one  side  of  the  upper 
jaw.  On  exploring  these  openings  with  a  sharp  steel  probe  a 
large  cavity  was  discovered  in  the  bone,  the  result  of  alveolar 
abscess,  the  presence  of  wliich  was  unsuspected  by  the  patient. 
On  inquiring  into  his  physical  condition  I  learned  that  for  the 
past  year  he  had  had  a  cough,  his  digestion  was  impaired,  and 
much  of  the  time  his  temperature  was  slightly  above  normal. 
He  had  frequently  consulted  his  family  physician  who  examined 
his  heart,  lungs,  sputum,  urine  and  blood.  These  gave  no  clue 
to  the  cause  of  ill  health.  His  appearance  indicated  a  toxemia. 
I  removed  several  teeth,  curetted  the  abscess  in  the  jaw  and 
followed  it  by  suitable  after-treatment.  His  fever  at  once  sub- 
sided, his  digestion  was  soon  much  improved,  his  cough  was 
lessened  and  finally  disappeared  altogether.  Although  seem- 
ingly his  physician  had  made  a  careful  examination  he  had 
overlooked  one  important  factor,  the  mouth. 

''Mrs.  C,  aged  thirty  years,  noticed  the  appearance  and  dis- 
appearance at  frequent  intervals  of  an  erythemic  patch  about 
the  size  of  a  silver  quarter  on  the  skin  over  the  left  canine  fossa. 
On  examining  the  mouth  for  a  possible  cause  for  this  reddened 
condition  of  the  skin  I  found  the  left  lateral  incisor  pulpless. 
There  was  no  sinus  and  the  tooth  had  given  no  trouble.  The 
only  e\^dence  of  disease  found  in  the  mouth  was  a  slight  hyper- 
emia of  the  gum  over  the  lateral  incisor  root  indicated.  The 
radiograph  showed  a  pus  cavity  in  the  bone  at  the  end  of  the 
root  about  the  size  of  a  large  pea.  Disinfection  of  the  root  did 
not  effect  a  cure.  I  made  an  opening  through  the  labial  wall  of 
the  alveolar  process,  excised  the  end  of  the  root  and  curetted 

^oThe  Illinois  Medical  Journal,  March,  1912. 


306  INTERSTITIAL    GINGIVITIS. 

the  cavity.    The  erythemic  patch  on  the  cheek  disappeared  and 
did  not  return. 

*'Mr.  S.,  aged  about  twenty-five  years,  was  directed  to  my 
clinic  for  the  treatment  of  a  chronic  abscess  in  the  upper  jaw 
in  the  vicinity  of  the  incisors  and  cuspid  which  had  proven  in- 
tractable to  ordinary  treatment.  His  physical  condition  was 
much  impaired,  he  was  emaciated,  his  skin  was  sallow,  his 
cheeks  hollow,  his  conjunctivas  pale,  eyes  dull,  and  his  lips  lacked 
the  color  of  health.  His  temperature  was  slightly  above  normal. 
I  could  elicit  no  history  of  any  other  illness,  recent  or  other- 
wise. His  appearance  gave  the  picture  of  a  toxemia.  In  this 
case,  likewise,  the  sharp  steel  probe  revealed  a  large  cavity  in 
the  bone,  extending  from  the  central  incisor  to  the  first  molar. 
On  Oct.  20,  1911,  I  extracted  the  cuspid  tooth  and  curetted  the 
bone  cavity.  On  Oct.  27th,  he  returned  to  the  clinic  much  im- 
proved. Nov.  10th,  his  color  was  normal,  his  eyes  clear,  and  he 
seemed  well." 

Dr.  T.  B.  Hartzell,  of  Minneapolis,  reports  the  following 
four  cases: 

''Case  1.  A  typical  case  of  pyorrhoea  alveolaris.  Patient, 
male,  aged  50  years.  Molar  and  bicuspids  in  both  lower  and 
upper  arches  freely  movable  in  sockets,  having  lost  the  bone 
to  about  one-half  of  the  original  depth  of  sockets,  pus  discharg- 
ing freely  from  the  sockets  about  the  teeth,  temperature  nor- 
mal, specific  gravity  of  urine  1018,  no  albumen,  no  sugar.  Pa- 
tient reports  a  tender  area  in  the  stomach  wall.  Diagnosis, 
ulcer  of  the  stomach  accompanied  by  chronic  dyspepsia.  Patient 
has  had  treatment  for  ulcer  of  the  stomach  for  two  years  with 
but  temporary  benefit.  The  treatment  in  this  case  was  first  ex- 
traction of  two  of  the  loose  teeth  followed  by  accurate  planing 
of  the  root  surfaces  of  all  the  teeth  which  had  lost  alveolar 
process.  Absolute  cessation  of  pus  flow.  Gums  resume  normal 
tint  and  after  two  months  no  tenderness  in  the  region  of  the 
ulcer,  digestion  about  normal. 

''Case  2.  Male,  aged  48.  Chronic  pain  and  tenderness  in  the 
masseter  muscles  of  the  left  side.  Tenderness  of  the  sublingual 
glands  and  torticollis.    Tenderness  of  left  shoulder  joint.    Ex- 


CONSTITUTIONAL   EFFECTS    OF    PYORRHCEA.  307 

amination  of  the  mouth  revealed  dead  pulp  in  left  lower  8  with 
free  pus  discharge  from  deep  pyorrhoea  pockets.  Left  lower  6 
and  7  vital  pyorrhoea  pockets  one-third  the  depth  of  the  root. 
General  pyorrhoea  of  all  the  molars  and  bicuspids  on  both  sides 
of  the  mouth.  Chronic  acid  indigestion  with  constant  eructa- 
tion of  gas  after  the  ingestion  of  food.  Treatment,  extraction 
of  loose  left  lower  8.  Planing  of  the  root  surface  of  all  the 
teeth  affected  by  pyorrhoea.  Pockets  were  pencilled  with  tinc- 
ture of  iodin.  After  two  weeks,  rheumatic  pains  in  shoulder 
and  tenderness  of  sublingual  glands  disappeared.  Digestion 
improved.  End  of  fourth  week  all  inflammatory  symptoms  con- 
tiguous to  the  teeth  absent.  Teeth  no  longer  tender  on  occlu- 
sion. Patient  has  resumed  vigorous  mastication  of  food.  End 
of  two  months  all  symptoms  of  dyspepsia  absent.  This  case  is 
typical  of  a  group  of  five  cases  in  which  joint  involvements  have 
been  present  from  one  to  three  years  which  have  all  disappeared 
upon  the  stamping  out  of  oral  infections. 

''Case  3.  Mrs.  J.,  aged  about  50,  with  mild  inflammation  of 
the  gum  margins.  Abscess  in  the  region  of  left  upper  2  pen- 
etrating the  palatal  tissues  an  inch  and  a  quarter.  Patient 
enjoys  moderately  good  health  though  a  constant  sufferer  from 
constipation,  rheumatism  of  the  arms,  wrists  and  fingers,  and 
of  the  feet,  ankles  and  knees.  Pains  sufficiently  sharp  on  rising 
to  cause  marked  discomfort.  Draining  of  the  abscess  and  treat- 
ment of  the  interstitial  gingi^dtis  results  after  two  months  in 
complete  freedom  from  rheumatic  pain  and  also  freedom  from 
constipation. 

''Case  4.  Miss  A.,  aged  26,  suffered  chronic  dyspepsia  and 
neurasthenia.  Has  been  treated  for  three  years  in  various 
sanatoria  and  has  also  spent  two  A^dnters  in  Southern  Califor- 
nia. Patient  presented  the  winter  of  1906.  Mentally,  much 
depressed.  Physically,  very  weak.  Weight,  86  pounds.  No 
albumen,  no  sugar.  All  the  teeth  exceedingly  loose.  Deep 
pockets  discharging  pus  freely.  Teeth  all  extracted  except  four 
in  the  upper  and  four  in  the  lower  jaw.  These  eight  teeth  were 
treated  for  pyorrh.opa  and  although  they  were  so  placed  that  they 
were  of  no  value  for  mastication  the  patient  showed  a  marked 
improvement.    At*  the  end  of  one  week  had  gained  one  pound  in 


308  INTERSTITIAL    GINGIVITIS. 

weight  altliougli  obliged  to  subsist  largely  upon  liquids.  Arti- 
ficial dentures  were  placed,  and  the  patient  increased  in  weight 
steadily  at  the  rate  of  a  pound  a  week  until  her  normal  weight 
of  106  pounds  had  been  regained,  after  which  time  she  returned 
to  her  home. ' ' 

Dr.  David  J.  Davis,''  Pathologist  of  St.  Luke's  Hospital,  re- 
ports the  following:  ''Pyemia,  septicemia,  meningitis,  neuritis, 
endocarditis,  etc.,  as  acute  infections  originating  from  alveolar 
abscesses  and  infected  food  about  the  teeth,  are  well  known  oc- 
currences. Chronic  generalized  or  systemic  infections  are  rarer 
and  less  commonly  recognized.  As  an  illustration  I  may  men- 
tion briefly  one  rather  striking  case  which  came  under  my 
observation. 

"A  young  man  had  been  suffering  for  several  weeks  with 
symptoms  of  severe  multiple  neuritis  associated  with  some 
anaemia,  marked  emaciation  and  slight  fever.  The  joints  were 
not  involved  and  physical  examination  revealed  no  heart  lesion. 
For  a  long  time  the  patient  had  been  troubled  with  severe  pyor- 
rhoea and  at  the  time  of  examination  the  gums  of  the  lower  jaw 
were  red  and  swollen,  bled  easily  and  on  pressure  abundant 
pus  exuded  from  between  teeth  and  gums.  Smear  and  culture 
examination  of  this  pus  revealed,  in  nearly  pure  growth,  many 
Gram-positive  diplococci  resembling  pneumococci.  The  colonies 
produced  a  green  zone  on  blood-agar  and  the  organism  acidi- 
fied and  coagulated  milk  and  fermented  inulin.  A  blood-culture 
made  by  taking  several  cubic  centimeters  of  blood  from  the  vein 
at  the  elbow  yielded  in  each  of  three  inoculated  culture-tubes  a 
pure  growth  of  the  same  diplococcus.  In  animals  this  organism 
was  not  highly  pathogenic.  One  broth-culture  intraperitoneally 
would  kill  guinea-pigs  in  twenty-four  to  forty-eight  hours.  Two 
rabbits  were  inoculated  repeatedly  with  large  amounts  of  cul- 
ture mthout  manifesting  serious  or  fatal  effects.  Apparently 
these  diplococci  are  identical  with  the  cocci  often  found  in  endo- 
carditis and  called  endocarditic  cocci  and  they  are  also  probably 
identical  with  the  diplococcus  almost  constantly  found  in  the 
mouth  and  usually  called  Streptococcus  viridans  (Schottmliller . 
I  may  say,  too,  that  they  appear  to  be  the  same  as  the  diplococci 


^Archives  of  Internal  Medicine,  April,  1912.     Vol.  IX,  pp.  505-514. 


CONSTITUTIONAL   EFFECTS    OF    PYORRHCEA.  309 

wliicli  I  have  found  at  times  in  the  tonsillar  crypts,  especially  in 
cases  of  endocarditis,  and  which  I  will  discuss  later  in  the  paper. 
In  this  particular  case  the  tonsils  were  carefully  examined  and 
appeared  to  be  normal  and  no  suspicious  foci  of  infection  other 
than  the  teeth  could  be  held  accountable  for  the  condition. 
Unfortunately,  the  patient  did  not  remain  long  under  observa- 
tion and  the  termination  is  not  known." 

Dr.  Edward  E.  Rosenow  of  the  Pathological  Laboratory, 
Rush  Medical  College,  says,  in  a  letter  to  the  author,  **  Clinical 
observation  convinces  me  that  the  low  grade  infections  about  the 
teeth,  etc.,  which  are  looked  upon  so  often  as  harmless,  are  far 
from  being  so.  The  evidence  is  practically  conclusive  that  endo- 
carditis may  have  its  origin  in  some  such  infection.  In  the  Sep- 
tember number  of  the  Journal  of  Infectious  Diseases  there  will 
appear  an  article  on  endocarditis  in  which  these  points  ^\t.11  be 
taken  up.  The  mechanism  of  how  the  organisms  which  are  so 
common  in  these  infections  about  the  teeth  can  produce  endo- 
carditis is  shown  experimentally  in  the  rabbit." 

At  the  meeting  of  the  American  Medical  Association  held  at 
Atlantic  City  in  June,  1912,  Dr.  E.  Libman  of  New  York  exhib- 
ited in  the  pathological  exhibit  a  series  of  twenty-two  hearts 
showing  bacterial  endocarditis  due  to  mouth  infection. 

Medical  literature  records  many  ailments  and  cures  of  dis- 
ease associated  with  pus  infection  in  the  mouth.  While  every 
practitioner  would  logically  reason  from  his  every-day  experi- 
ences that  there  is  a  relationship  existing  between  cause  and 
effect,  yet  more  absolute  data  in  the  way  of  research  is  neces- 
sary to  show  more  clearly  that  such  relationship  exists.  The 
work  of  Billings,  Rosenow,  Davis  and  others  should  be  con- 
firmed by  many  more  experiments  upon  animals  to  verify  these 
facts. 

The  author  is  one  of  those  who  believes  that  infections  of 
the  mouth  are  taken  into  the  stomach  mth  every  swallow;  and 
that  infection  of  the  glands  of  the  neck  as  well  as  absorption  of 
pus  directly  into  the  blood  and  carried  to  all  parts  of  the  body, 
occurs  in  a  large  percentage  of  our  patients,  because  he  has 
cured  many  thus  infected  and  improved  the  health  of  others  by 
putting  the  mouth  in  a  healthy  condition. 


CHAPTER  XXVIII. 

TREATMENT. 

The  treatment  of  interstitial  gingivitis  as  a  whole  is  very 
unsatisfactory  both  to  the  operator  and  the  patient.  The  clin- 
ical history  of  each  structure  is  essentially  that  of  any  other 
disease  of  the  mucous  membrane,  periosteum  and  bone  tissue. 
From  a  microscopic  viewpoint,  however,  as  illustrated  by  the 
author's  researches,  the  pathologic  aspect  is  quite  complicated, 
since  the  relation  of  tooth,  peridental  membrane,  alveolar  proc- 
ess and  gum  tissue  has  no  counterpart  in  any  other  part  of  the 
body. 

The  etiology  of  most  of  the  disease  to  the  dentist  is  obscure 
in  nearly  every  person  under  treatment,  as  there  are  consti- 
tutional factors  involved  in  connection  with  the  local  irritation. 
The  dental  specialist  not  having  a  medical  education  and  a  gen- 
eral knowledge  of  disease  intoxications,  the  faulty  metabolism 
and  lowered  resistance  are  not  understood. 

There  is  a  general  law  in  medicine  laid  down  many  years 
ago  that  to  treat  a  disease  successfully  the  cause  must  always 
be  removed.  In  those  patients  in  whom  the  cause  is  of  a  consti- 
tutional nature,  there  may  or  may  not  be  local  deposits.  The 
mere  cleansing  of  the  tooth  roots  and  local  treatment  ^\dll  not 
always  cure  such  conditions.  On  the  other  hand,  much  harm 
may  be  caused  (as  we  have  already  shown)  by  local  irritation, 
traumatic  lesions,  and  changes  in  function  w^hich  cause  the  tissue 
to  be  readily  acted  upon  by  irritants  in  the  blood  stream.  A 
large  percentage  of  interstitial  gingivitis  is  influenced  or  en- 
tirely due  to  constitutional  causes.  Interstitial  gingivitis 
under  such  circumstances  can  never  be  i)ermanently  reduced 
until  the  cause  has  been  ascertained  and  remedied.  A  very  thor- 
ough history  of  the  patient,  especially  age  and  condition  of  the 
urine,  should  be  obtained.  Such  data  ^^411  assist  the  specialist 
greatly  in  a  clear  understanding  of  his  method  of  procedure. 

We  have  shown  that  the  tooth,  so  far  as  this  disease  is  con- 


TREATMENT.  311 

cerned,  is  a  foreign  body  and  tlie  alveolar  process  is  an  endo- 
transitory  structure.  When  disease,  therefore,  whether  due  to 
local  or  constitutional  causes,  once  atfects  these  structures,  even 
if  they  be  restored  to  comparative  health,  they  are  more  easily 
involved  than  other  structures  of  the  body.  AVhen  inflammation 
has  once  taken  place  in  these  tissues,  whether  the  disease  be  due 
to  local  or  constitutional  causes,  the  operator  may  apparently 
restore  these  structures  to  health.  If,  however,  the  cause  is  not 
removed,  whether  it  be  local  or  constitutional,  the  disease  soon 
returns  as  it  is  of  a  progressive  nature.  This  necessitates  fre- 
quent \dsits  of  the  patient  for  further  treatment.  The  endo- 
transitory  nature  of  the  alveolar  process,  after  inflammation  has 
once  affected  the  part,  naturally  causes  the  disease  to  become 
chronic.  The  obscure  constitutional  causes  and  the  chronic  ten- 
dency of  the  disease  soon  causes  the  tooth  to  become  loose  and 
finally  exfoliated. 

When  the  disease  is  taken  in  hand  and  continually  treated 
before  the  bone  becomes  involved,  a  fair  success  may  be  ob- 
tained. I  have  demonstrated  that  bone  absorption  around  the 
teeth  as  one  grows  older  is  a  natural  process  which  cannot  be 
arrested  to  any  extent.  Toxins  and  irritations  assist  greatly, 
dependent  always  on  the  resistance  of  tissue  and  strength  of 
the  irritant.  Neglect  on  the  part  of  the  patient  to  massage  the 
gums  properly  twice  a  day  and  use  a  proper  gum  wash,  the 
irritants  in  the  blood  and  in  the  mouth,  cause  the  tissue  to  soon 
return  to  their  pathologic  state  when  the  bone  becomes  dis- 
eased, bmng  to  its  endo-transitory  nature.  Chronic  inflamma- 
tion once  set  up,  "eternal  vigilance"  on  the  part  of  the  oper- 
ator and  patient  is  the  onlj^  method  that  will  prevent  the  disease 
from  progressing  with  a  final  destruction  of  the  alveolar  process 
and  exfoliation  of  the  teeth. 

The  disorder  responds  quickly  to  treatment  at  its  outset. 
Later,  its  complications  and  the  extent  of  structure  involved, 
render  treatnient  very  inefficacious,  and  always  insure  loss  of 
the  tooth.  As  the  general  surgeon's  duty  is  to  save  life,  if  need 
be,  at  the  expense  of  limb  or  organ,  but  to  save  these  last  if  pos- 
sible, so  the  dental  surgeon's  duty  is  to  remove  loose  teeth,  if 
need  be,  for  the  benefit  of  the  gene  ''al  health,  but  to  save  them. 


312  INTERSTITIAL    GINGIVITIS. 

when  possible,  for  the  same  reason.  The  patient,  therefore, 
shoiikl  be  tohl  frankly  at  the  outset  of  interstitial  gingivitis, 
that  it  is  a  condition  requiring  time  for  its  treatment,  and  should 
not  be  given  that  prognosis  too  frequently  made  of  quick  cure. 
To  such  a  prognosis  many  a  case  of  constitutional  disorder  is 
due.  The  dentist  is  a  practitioner  of  a  surgical  specialty,  not  a 
mere  tooth-puller.  The  surgical  side  of  dentistry  has  received 
too  much  attention,  however;  the  medical  or  prophylactic  too 
little.  Patients  are  beginning  to  pay  more  attention  to  the  pro- 
phylaxis of  diseases  of  the  teeth  and  jaws,  and  need  but  little 
encouragement  and  instruction  to  see  the  absolute  necessity  of 
early  prophylaxis  and  treatment  of  interstitial  gingivitis.  The 
trend  in  general  medicine  is  to  prophylaxis,  and  this  has  un- 
doubtedly so  impressed  patients  as  to  open  the  way  for  dental 
prophylactic  suggestions.  Viewing  the  question  from  the  narrow- 
est standpoint  of  remuneration,  the  dentist  could  not  fail  to  profit 
by  instructions  to  his  patients  on  prophylaxis.  He  certainly 
fails  in  his  duty  as  the  member  of  a  learned  profession  by  not 
doing  this.  Furthermore,  with  the  known  necessity  for  pro- 
phylaxis, it  is  an  open  question  whether  the  failure  to  inform 
the  patient  of  the  dangers  of  the  incipient  disease  could  not  be 
successfully  pleaded  as  a  basis  for  a  malpractice  suit. 

From  the  etiology  of  this  disease,  the  treatment  would  ap- 
pear simple  and  easy. 

Early  diagnosis  is  not  difficult,  since  the  simple  inflammation 
of  the  gums  is  easily  recognized  by  the  patient.  Bleeding  when 
the  toothbrush  or  toothpick  is  used  can  never  be  mistaken. 
The  dentist  wdth  his  accomplished  eye  can  readily  detect  the 
slightest  change  in  color  or  puffiness  around  the  necks  of  the 
teeth  or  of  the  festoons  between  the  teeth.  Kedness,  puffiness 
and  bleeding  are  pathognomonic  of  this  disease  in  its  incipiency. 
Few  dentists  have,  hoAvever,  given  this  stage  of  the  disease 
any  thought,  albeit  they  have  filled  the  teeth  of  their  patients 
from  year  to  year.  I  have  in  mind  three  patients  with  loose 
teeth  and  inflammation  extending  throughout  the  peridental 
membrane  and  alveolar  process,  who  had  been  under  an  old 
practitioner  now  retired  from  practice.  The  patients  had  never 
had  the  gums  treated  or  even  their  teeth  cleaned.    This  is  not 


TREATMENT.  313 

an  uncommon  occurrence.  The  excuse  usually  made  by  the  den- 
tist is  that  he  cannot  get  paid  for  his  time.  Gingivitis  is  a  dis- 
ease which  the  dentist  is  as  much  bound  to  treat  and  cure  as  any 
disease  of  the  mouth  and  teeth.  It  is  a  part  of  his  specialty 
which  should  not  be  ignored.  It  is  claimed  that  the  dental  pro- 
fession is  overcrowded.  Were  this  disease  treated  until  the 
gums  were  placed  in  a  healthy  condition,  there  would  be  prac- 
tice enough  for  as  many  more  dentists  as  there  are  today.  The 
busy  dentist  of  today  could  attend  only  to  one-half  the  patients 
whom  he  now  serves. 

The  treatment,  then,  should  be  prophylactic  in  its  nature, 
preventive  rather  than  corrective.  The  disease  and  treatment 
is  not  unlike  an  inverted  pyramid :  the  farther  from  the  apex  or 
beginning,  the  more  difficult  and  hopeless  the  task  becomes. 
Since  the  teeth  have  nothing  directly  to  do  wdth  this  disease, 
they  should  be  ignored.  In  the  early  stages,  the  gums  should 
receive  proper  attention.  These,  like  other  parts  and  organs  of 
the  body,  must  be  exercised  and  kept  clean  to  be  healthy.  The 
gums  should  be  properly  massaged,  just  as  the  liver,  kidneys 
or  skin  are  when  they  are  not  doing  proper  work.  This  can  be 
accomplished  by  properly  made  brushes.  The  ordinary  tooth- 
brush is  not  adapted  to  the  w^ork  under  discussion.  It  will 
brush  the  teeth  but  not  reach  the  gums.  What  is  needed  is  a 
massage  brush  that  will  miss  the  teeth  to  a  certain  extent,  but 
^^^ll  reach  the  gums  and  contract  them  tight  around  the  teeth. 


Fig.  99. — The  Author's  Gum  ^fASSAGE  Brush. 

thus  preventing  the  accumulation  of  foreign  substances.  The 
patient  should  be  instructed  with  this  single  idea  in  view,  ''that 
the  gum  margin  is  to  be  exercised  and  stimulated  and  not  the 
teeth,  which  must  be  ignored."  A  brush,  properly  made  for 
gum  massage  (Fig.  99),  will  do  sufficient  work  upon  the  teeth 
with  the  aid  of  the  floss  silk  and  toothpick.     It  should  have 


314  INTERSTITIAL    GINGIVITIS. 

printed  upon  the  handle,  in  large  letters,  ''gum  massage 
brush."  The  handle  should  be  bent  a  little  more  than  the  "pro- 
phylactic," so  that  the  end  containing  the  bristles  can  be 
brought  in  contact  with  the  gum,  posterior  to  the  central  in- 
cisors, upper  and  lower,  and  around  the  third  molar  teeth. 
There  should  be  a  tuft  of  bristles  at  the  point  with  a  space  for 
the  teeth.  The  tuft  should  be  longer  than  those  on  the  body  of 
the  brush.  This  tuft  will  reach  the  gums  at  all  points  inside  of 
the  mouth  and  around  the  molars.  The  bristles  on  the  body 
must  have  spaces  between  them,  so  that  when  the  upward  and 
downward  movement  is  given,  the  bristles  will  go  between  the 
teeth  and  reach  the  gum  festoons.  The  bristles  must  be  medium 
and  hard.  The  quality  of  bristles  must  depend,  however,  upon 
the  condition  of  the  gums.  If  they  be  soft  and  spongy,  the 
medium  may  be  used.  If  the  processes  are  heavy  and  thick,  the 
gums  swollen  and  engorged  with  blood,  hard  bristles  must  be 
used.  Soft  bristles  (although  sometimes  recommended)  should 
never  be  used. 

The  antique  theory  that  vigorous  stimulation  is  injurious  is 
too  much  accepted.  Barrett,^  for  example,  says,  "massage  of 
the  gums  with  the  ball  of  the  finger  and  by  the  frequent  use  of  a 
rather  soft  brush  should  be  resorted  to."  Boedecker'  remarks 
that  too  frequent  application  of  the  toothbrush  is  sufficient  to 
produce  papillary  hyperplasia.  Tomes  ^  says,  "in  my  own  expe- 
rience I  have  found  that  frequent  and  vigorous  rubbing  of  the 
gums  with  the  finger,  shampooing  them  in  fact,  has  often  been 
productive  of  great  advantage,  the  patient  of  course  being  cau- 
tioned not  to  rub  the  actual  edge;  but  even  on  this  point  there 
is  difference  of  opinion,  for  in  a  recent  paper  on  the  subject, 
rest  and  the  avoidance  of  all  friction  is  advocated."  Dr.  Meyer 
L.  Ehein,*  in  introducing  the  "Prophylactic  Toothbrush"  to  the 
profession,  says,  in  his  article  on  "Oral  Hygiene,"  each  brush 
comes  inclosed  in  an  envelope,  upon  which  are  printed  directions 
for  the  intelligent  use  thereof,  and  the  following  caution: 
* 'Never  pass  the  brush  across  the  teeth,  as  this  movement  de- 


1  Dental  Cosmos,  1883,  page  532. 

^  Anatomy  and  Pathology  of  the  Teeth,  page  365. 

'  Dental  Surgery,  page,  704. 

*  New  England  Journal  of  Dentistry,  October,  1884. 


TREATMENT. 


315 


stroys  the  delicate  membrane  which  attaches  the  gum  to  the 
teeth,  causing  recession  of  the  gum,  and  ultimate  loosening  and 
loss  of  the  teeth. ' '  Citations  of  this  could  be  multiplied,  show- 
ing the  general  impression  is  that  the  gums  should  not  be  stim- 
ulated to  any  great  extent ;  that  the  finger,  a  soft  cloth,  or  a  very 
soft  toothbrush  alone  should  be  employed.  The  use  of  the  finger 
is  a  superstition  which  is  handed  down  from  generation  to  gen- 
eration without  the  slightest  critical  analysis.  If  the  advocate 
of  this  use  would  try  the  experiment,  he  would  see  how  impos- 
si])le  it  would  be  to  bring  it  in  contact  with  all  the  tissues  of  the 
mouth  that  are  involved  in  this  disease;  were  it  possible,  the 
fingers,  cloth  and  soft  toothbrush  would  not  accomplish  the 
desired  result. 

No  brush  should  be  used  whose  bristles  are  softer  than  the 
medium;  very  often  these,  used  once  or  twice  and  dipped  into 
water  or  mouth  washes,  become  so  soft  as  to  be  wholly  unfit  for 
use.  It  is  always  a  good  plan  to  have  two  brushes  to  be  used  on 
alternate  days.  In  this  way  one  can  dry  while  the  other  is  being 
used.  The  general  opinion  has  been  that  friction  upon  the  gums 
was  detrimental  on  account  of  the  resultant  tendency  to  absorp- 
tion of  the  gums.  AVhile  this  may  exceptionally  be  true,  it  is 
not  true  of  a  majority.  Should  milk,  arsenic,  iron,  strychnine  or 
quinine  be  entirely  abolished  as  remedies  because  occasionally  a 
person  presents  untoward  effects?  If  the  alveolar  process  be 
very  thin  over  the  roots  of  the  teeth,  especially  the  cuspids,  the 
patient  must  be  instructed  to  use  the  brush  so  as  not  to  over- 
stimulate  these  particular  parts.  In  such  cases  the  inner  alveo- 
lar process  and  gum  tissues  may  be  stimulated  with  impunity 
and  with  the  hardest  brush.  Again,  if  the  chronic  interstitial 
gingivitis  be  of  long  standing,  or  even  if  chronic  gingivitis  has 
been  present  for  some  time,  stimulation  of  the  brush  "\\ill  cause 
the  gums  and  mucous  membrane  to  recede  until  hard,  sound, 
healthy  bone  structure  has  been  secured.  Then  absorption  for 
the  time  being  will  practically  cease.  In  most  cases  absorption 
and  contraction  of  the  gum  tissue  will  take  place  to  a  more  or 
less  marked  degree.  If  absorption  of  the  alveolar  process  has 
taken  place  and  the  gums  are  puffy,  red  and  swollen,  a  disease 
exists,  to  be  cured,  regardless  of  consequences.     The  alveolar 


316  INTERSTITIAL    GINGIVITIS. 

process  and  gums  will  never  return  to  their  original  position, 
but  it  is  a  decided  advantage  to  have  a  healthy  mouth,  even  if 
the  alveolar  process  and  gums  have  slightly  receded. 

I  have  used  medium  and  stiff  brushes  in  my  practice  for  the 
last  thirty  years  and  have  failed  to  see  any  ill  results.  For  the 
past  sixteen  years  I  have  made  constant  experiments,  with  the 
view  of  securing  the  proper  shape  and  stiffness  of  the  bristles 
and  have  obtained  uniform  results  in  gum  treatment. 

Proper  employment  of  the  ''gum  massage  brush"  requires 
skill.  Every  dentist  should  train  his  patient  in  the  method  of 
using  the  brush.  The  gingival  borders  should  not  only  be  stim- 
ulated, but  the  bristles  should  be  passed  in  between  the  gum 
margin  and  the  tooth  so  as  to  remove  the  debris  and  exfoliated 
epithelial  scales  which  have  accumulated  therein.  These  are 
often  the  cause  of  the  irritation.  Unless  this  is  done  the  gum 
or  epithelial  tissue  cannot  perform  its  functions  or  be  restored 
to  health.  Stimulating  astringents  and  germicidal  mouth 
washes  should  be  employed  whenever  the  gums  are  massaged. 
One  of  the  best  gum  washes  is  that  suggested  by  Dr.  W.  H. 
Whitslar,^  of  Cleveland,  Ohio,  the  principal  drug  of  which  is 
sulphocarbolate.  This  drug  may  be  used  in  different  strengths 
and  in  many  forms.     I  use  the  following: 

Gum  Wash. 

Zinc  sulphocarbolate   gr.  60 

Alcohol    oz.     1 

Distilled  water   oz.     2 

True  oil  of  wintergreen gtts.     8 

The  massage  should  be  done  three  times  a  day.  The  patient 
should  be  under  the  care  of  the  dentist  at  least  twice  or  thrice 
a  week,  so  that  he  may  direct  the  treatment.  If  the  teeth  are 
irregular,  care  and  patience  are  required  to  reach  the  festoons 
between  the  teeth.  After  the  gums  are  in  perfect  health,  the 
patient  should  visit  his  dentist  at  least  four  times  a  year,  or 
even  oftener  if  necessary,  for  inspection.  If  on  inspection  the 
gums  be  found  diseased  at  any  point,  the  dentist  can  direct  the 
attention  of  the  patient  to  the  particular  locality  and  the  disease 
be  eradicated.    By  this  method  and  this  alone  can  the  gums  be 


"Dental  Summary,  1907,  No.  8. 


TREATMENT.  317 

kept  in  a  healthy  condition.  Each  patient  must  be  given  specific 
directions  as  to  the  treatment  of  his  or  her  case. 

When  the  patient  seeks  our  services,  we  should  decide  by  a 
thorough  examination  whether  the  disease  is  due  to  local  or 
constitutional  causes  or  both.  The  age  of  the  patient,  condition 
and  character  of  deposits,  if  any,  condition  of  mouth,  jaws  and 
dental  arches,  condition  of  urine,  occupation  and  everything 
pertaining  to  the  patient  should  be  considered.  While  this  ex- 
amination is  being  conducted,  which  requires  a  few  days,  the 
local  treatment  may  be  undertaken.  This  consists  of  an  appli- 
cation to  the  mouth,  gums,  mucous  membrane  and  teeth  of  a 
germ  destroyer  every  other  day  until  the  parts  are  in  an  aseptic 
condition  as  far  as  possible. 

I  cannot  here  too  strongly  condemn  the  method  of  starting 
the  treatment  of  this  disease  by  scraping  the  roots  of  teeth 
which  may  or  may  not  have  calcic  deposits,  wounding  the  soft 
tissues  and  infecting  them  without  first  rendering  them  as 
aseptic  as  possible.  Asepsis  is  always  the  first  precept  of  the  sur- 
geon before  any  kind  of  an  operation.  Why  should  the  dentist 
be  exempt  from  similar  methods?  It  is  fortunate  for  the  den- 
tist that  stasis  of  blood  prevents  infection  to  a  great  extent  or 
serious  results  might  occur. 

This,  however,  dees  not  justify  the  vicious  treatment  em- 
ployed, since  the  method  of  procedure  is  wholly  unscientific  and 
not  in  harmony  with  good  practice. 

THE   lODIN   TREATMENT. 

The  operator  is  not  justified  in  placing  his  fingers  in  the 
filthy  mouths  of  his  patients.  This  is  also  true  of  the  students 
in  the  clinics  of  our  dental  schools.  It  is  in  the  clinic  where  the 
student  should  be  taught  the  object  lesson  of  cleanly  mouths 
before  operations.  No  patient  in  the  clinic  or  in  private  prac- 
tice should  be  operated  upon  before  a  thoroughly  aseptic  mouth 
has  been  obtained.  The  method  is  so  simple  and  so  easily  per- 
formed that  only  a  few  minutes  is  required  before  operation 
may  be  commenced.  This  treatment  should  consist  of  the  free 
use  of  iodin  applied  to  the  gums  and  teeth,  carrying  it  well  up 
into  the  pockets.  This  will  destroy  every  germ  with  which  it 
comes  in  contact.     After  many  years  of  experimentation,  sur- 


318  INTERSTITIAL    GINGIVITIS. 

geons  have  come  to  realize  that  iodin  is  the  quickest  acting  and 
best  germicide  we  now  possess.  The  author,  when  he  began  his 
researches  in  1878,  commenced  the  use  of  iodin  and  has  used 
it  to  the  exclusion  of  all  other  drugs  in  the  treatment  of  this 
disease.    The  results  obtained  are  all  that  can  be  desired. 

The  official  tincture  of  iodin  contains  seven  per  cent  of  iodin 
dissolved  in  alcohol  to  which  is  added  five  per  cent  of  potassium 
iodid.  This  preparation,  if  used  often,  will  cause  the  membrane 
to  become  tender  and  sore ;  it  will  also,  in  some  patients,  destroy 
the  mucous  surface.  To  overcome  this  difficulty,  many  years 
ago,  I  formulated  the  following  which  I  have  called 
iodoglycerole : 

Zinc  iodid 15  parts  or  grams 

Water  10  parts  or  grams 

Iodin   ' 25  parts  or  grams 

Glycerin    50  parts  or  grams 

As  compared  with  the  ordinary  tincture  of  iodin,  its  astrin- 
gent and  antiseptic  properties  are  greatly  increased,  the  glycerin 
causes  rapid  absorption  and  the  irritating  effects  are  reduced 
to  a  minimum.  The  penetrating  effect  is  remarkable.  The 
glycerin  thickens  the  preparation  and  prevents  it  from  mixing 
with  the  saliva  and  running  over  the  mouth  as  the  ordinary 
tincture  will  do.  Long,  round,  wood  applicators  can  be  obtained 
at  the  drug  and  instrument  houses  and  on  one  end  cotton  is 
wound;  this  is  saturated  with  the  preparation  and  the  gum 
margins  above  and  below  painted.  The  jaws  are  closed,  the 
lips  and  cheeks  distended  and  the  application  made  as  before ; 
the  teeth  are  also  covered;  the  lips  and  cheeks  are  held  away 
from  the  jaws  until  the  iodin  has  dried. 

These  applications  should  be  made  every  other  day  and  con- 
tinued until  the  patient  is  dismissed.  In  a  fairly  clean  mouth, 
the  process  of  removing  the  local  causes  may  be  commenced  at 
the  second  appointment  or  possibly  at  the  first  sitting  after  the 
iodoglycerole  has  become  dry.  In  the  more  filthy  mouths,  the 
time  to  commence  operations  will  depend  upon  the  judgment  of 
the  operator  and  the  condition  of  the  mouth  under  treatment. 

In  those  patients  who  are  having  operations  upon  the  teeth. 


TEEATMENT.  319 

although  their  gums  are  in  fairly  good  condition,  they  are  treated 
after  each  sitting  to  destroy  lactic-acid  bacilli  and  their  ferment 
and  all  other  foreign  and  undesirable  material  in  the  mouth, 
thus  preventing  tooth  decay.  By  this  method  of  procedure,  I 
have  reduced  decay  of  the  teeth  from  thirty  to  forty  per  cent 
in  my  patients  in  the  past  ten  years.  While  this  treatment  is 
being  conducted  by  the  operator,  the  patient  should  use  the  gum 
wash  twice  a  day  as  directed.  After  the  patient  has  been  dis- 
missed the  gum  wash  should  be  used  continually  once  a  day. 

Having  destroyed  all  the  germs  in  the  mouth  including  pus 
germs  (except  perhaps  in  so-called  pockets  out  of  reach  with  the 
iodoglycerole)  and  contracted  the  gums,  more  or  less,  about  the 
necks  of  the  teeth  and  on  to  the  bone,  exploration  of  the  mouth 
for  local  irritants  and  irregularities  may  now  be  undertaken. 

Erupting  Teeth,  whether  the  first  or  second  set,  should  be 
examined  by  the  operator  and  the  inflamed  gums  receive  the 
iodoglycerole  treatment.  This  procedure  should  be  continued 
in  the  public  schools  among  the  poor  children  as  well  as  at  the 
homes  of  the  well-to-do.  If  the  iodoglycerole  gum  bath  was 
introduced  into  the  public  schools,  contagions  and  infections 
would  be  reduced  to  a  minimum. 

MODERN  DENTISTRY. 

I  have  stated  that  modern  dentistry  has  produced  disease  of 
the  gums,  pericemental  membrane,  and  alveolar  process  more 
than  any  one  cause.  The  education  of  the  student  in  the  dental 
schools  in  the  mechanics  of  dentistry  has  been  conducted  to  the 
exclusion  of  the  pathology  of  the  mouth.  The  mechanics  have 
been  carried  far  beyond  normal  physical  tolerance.  The  dis- 
covery that  pus  formation  in  alveolar,  pericemental  and  blind 
abscesses  and  the  accumulation  of  pus  about  the  alveolar  proc- 
ess and  roots  of  the  teeth  cause  many  of  the  diseases  of  the 
human  body  is  a  just  evidence  of  the  necessity  of  a  medical  edu- 
cation of  the  dentist.  Not  until  the  methods  of  teaching  have 
been  reconstructed,  can  we  expect  any  improvement  from  the 
pathologic  standpoint  in  the  management  of  the  mouth  and  teeth. 
The  local  causes  which  bring  about  interstitial  gingivitis  have 
been  discussed  in  Cliapter  XVII  and  every  teacher  and  practi- 
tioner is  familiar  with  them,  hence  it  is  hardly  necessary  to 


320  INTERSTITIAL    GINGIVITIS. 

discuss  the  question  here.  It  is  to  be  hoped  that  the  profession 
will  soon  consider  the  pathology  of  our  specialty  and  so  far  as 
possible  correct  and  prevent  local  irritations,  inflammations  and 
abscesses. 

In  passing*  this  subject,  however,  there  are  a  few  suggestions 
which  may  be  offered  here.  There  is  no  excuse  for  the  whole- 
sale movement  of  teeth  without  extraction.  The  specialist 
should  make  a  study  of  the  jaws  and  teeth  of  each  patient  to 
ascertain  how  much  may  be  accomplished  with  as  little  move- 
ment of  the  teeth  as  possible.  This  is  to  be  frequently  accom- 
plished by  the  sacrifice  of  one  or  more  teeth.  The  health  of  the 
patient,  as  well  as  the  causing  of  as  little  inflammation  in  the 
alveolar  process  as  possible,  should  be  the  foremost  thought  in 
the  mind  of  the  operator.  The  frequent  use  of  iodoglycerole  is 
indicated  during  the  operation  of  correcting  irregular  teeth  to 
keep  down  the  inflammation.  After  the  retaining  bands  have 
been  adjusted  the  iodoglycerole  should  often  be  used. 

We  have  shown  that  the  condition  of  the  alveolar  process, 
especially  after  it  has  attained  its  growth  and  its  endo-transi- 
tory  nature,  is  a  very  unfavorable  structure  for  the  successful 
operation  for  the  implantation  or  transplantation  of  teeth,  par- 
ticularly so  when  the  peridental  membrane  is  not  present. 

Gold  Crowns  and  Bands  should  only  extend  to  the  gum  mar- 
gin and  never  above  it  except  in  extreme  cases. 

Artificial  Dentures  should  be  so  constructed  as  to  produce 
the  least  amount  of  irritation  possible.  The  larger  the  surface 
the  better  the  adaptation.  Iodoglycerole  treatment  to  the  sur- 
face of  the  mucous  membrane  under  the  plate  to  destroy  germs 
and  reduce  inflammation  should  be  frequently  applied. 

Individual  Teeth  wdiose  function  is  not  restored  from  want 
of  proper  articulation — too  great  or  not  sufficient  pressure — 
must  be  corrected.  Such  teeth  are  liable  to  become  diseased,  like 
any  other  organ  or  structure  of  the  body  when  not  properly 
exercised  takes  on  pathologic  changes  according  to  the  tissue 
involved. 

Tartar  upon  the  teeth  acts  as  a  local  irritant  and  should 
always  be  removed.  In  some  mouths  it  accumulates  rapidly  and 
must  be  removed  as  often  as  once  a  month ;  in  other  mouths  no 


TREATMENT. 


321 


tartar  is  present.  The  teeth  in  such  patients  should  be  cleaned 
as  often  as  twice  a  year.  These  suggestions,  however,  are  only 
given  out  approximately,  since  the  operator  must  decide  by  the 
conditions  as  they  exist  how  often  visits  should  be  made  to 
obtain  the  best  results.  Having  destroyed  the  germs  in  the 
mouth  and  about  the  teeth  by  the  free  use  of  iodoglycerole,  the 
tartar  may  be  removed  without  fear  of  infecting  the  tissues  and 
with  a  large  degree  of  comfort  to  the  operator  on  account  of  a 
clean  mouth.  Laceration  of  the  gums  in  performing  this  oper- 
ation is  desirable.  It  removes  the  excess  of  stagnant  blood  from 
the  tissues  and  greatly  assists  in  restoring  normal  circulation. 
Three  decades  ago,  I  advocated  the  following  set  of  scalers: 

They  consist  of  handles,  shanks  bent  at  different  angles,  and 
three  cornered  blades,  so  that  they  can  be  used  in  three  direc- 
tions without  removing  the  fingers  from  the  tooth  (Fig.  100). 


Fig.  100. — The  Author's  Set  of  Scalers. 

These  are  all  delicately  made  and  tempered  very  hard.  Sharp 
edges  are  thus  retained.  They  will  reach  every  point  where 
tartar  can  collect.  After  the  deposits  have  been  fairly  well  re- 
moved, the  gums  may  be  syringed  with  hot  water  to  remove 
the  debris.  The  gums  should  then  be  saturated  with  iodoglycer- 
ole and  the  patient  dismissed.  Applications  should  be  made 
every  two  or  three  days.  The  gums  w411  contract  and  healthy 
circulation  follow.     The  gum  massage  with  the  gum  w^ash  will 


322  INTERSTITIAL    GINGIVITIS. 

now  be  used  twice  a  day.  After  a  few  treatments  and  the  con- 
stant use  of  the  massage  brush,  the  gums  will  contract  and  other 
deposits  which  were  not  perceptible  at  the  first  sitting  will  now 
be  presented  to  view.  This  method  of  treatment  should  be  con- 
tinued until  the  gums  and  alveolar  process  are  restored  to 
health.  The  patient  should  return  to  the  dentist  as  often  as 
necessary  (every  month  or  two)  to  have  the  gums  examined 
and  for  further  instructions. 

As  has  been  already  shown,  chronic  interstitial  gingivitis 
may  extend  only  to  the  peridental  membrane,  to  the  periosteum, 
or  it  may  extend  throughout  the  alveolar  process  with  the  ab- 
sorption of  the  bone  the  entire  length  of  the  root  of  the  tooth. 
Pus  infection  and  calcic  deposit  may  or  may  not  take  place.  In 
the  early  stages  of  this  progressive  inflammation,  the  first  is 
probable.  If  pus  and  deposits  are  present  they  can  be  treated 
with  signal  success  according  to  the  symptoms  and  as  herein- 
after explained.  As  already  suggested,  the  gum  massage  brush 
must  be  vigorously  used  to  relieve  the  engorged  tissues  of  blood. 
Since  absorption  of  the  alveolar  process  depends  upon  irritation 
and  inflammation,  this  must  be  removed  as  quickly  as  possible. 

In  the  treatment  of  deep-seated  interstitial  inflammation, 
iodin  or  iodin  and  aconite  has  always  been  regarded  by  physi- 
cians and  surgeons  as  the  best  remedy.  The  gums  should  be 
thoroughly  saturated  twice  or  thrice  weekly,  as  already  sug- 
gested. If  the  alveolar  process  be  so  absorbed  that  the  tooth  has 
become  loose,  the  case  is  hopeless.  In  such  unstable  tissues, 
especially  when  inflammation  extends  through  the  process  and 
lacunar,  perforating  canal  absorption  and  halisteresis  is  going 
on,  reversal  of  the  order  so  as  to  set  the  osteoblasts  to  tissue- 
building  is  hardly  to  be  expected.  The  tendency  is  to  destroy 
and  not  restore  the  alveolar  process.  In  such  cases  the  tooth 
must  be  fastened  to  the  other  teeth  perfectly  tight  to  prevent 
motion  in  any  direction.  The  movement  of  the  tooth  in  masti- 
cation intensifies  the  irritation,  which  in  time  only  increases  the 
absorption.  Liberal  use  of  iodin  and  the  gum  massage  brush  is 
all  that  can  be  done  to  reduce  the  inflammation  and  absorption 
as  much  as  possible.  The  exfoliation  is  only  a  matter  of  time. 
If  the  tooth  or  teeth  cannot  be  retained  perfectly  tight,  no  mat- 


TKEATMENT. 


323 


ter  liow  liealthy  tlie  surrounding  tissues  may  be  restored,  the 
irritation  produced  Ly  the  loose  teeth  will  soon  set  up  inflam- 
mation in  the  surrounding  tissues.  The  sooner  the  loose  teeth 
are  removed  the  better.  In  no  case  can  the  bone  tissue  be  re- 
stored, if  the  matrix  or  cartilage  be  destroyed,  since  in  this  the 
osteoblasts  are  located.  If  the  matrix  or  cartilage  be  destroyed, 
a  fibrous  union  (such  as  occurs  in  the  case  of  implanted  teeth 
and  the  imbedding  of  foreign  bodies  in  the  tissues  of  the  body) 
only  is  possible. 

If  inflammation  has  extended  into  the  periosteum,  peri- 
dental membrane  and  alveolar  process,  calcic  deposits  are  fre- 
quently  found  upon  the  roots  of  the  teeth.  When  this  has  taken 
place,  the  calculus  must  be  removed.  This  should  be  done  with 
the  utmost  care,  in  order  that  adjacent  tissues  may  not  be  in- 
jured, or  inflamed  parts  infected  mtli  pus  germs.  Since  dead 
bone  is  not  present,  the  operator  should  confine  his  instrumenta- 
tion entirely  to  the  root  or  roots  of  the  teeth,  with  as  little  injury 
as  possible  to  the  adjacent  tissues.     The  alveolar  process  must 


Fig.  101. — Spoon  Shaped  Excavators  for  Scaling  the  Roots  of  Teeth. 

under  no  consideration  be  touched.  Eiggs  believed  that  the  edge 
of  the  alveolar  process  was  always  in  a  state  of  disintegration, 
and  that  it  should  be  so  scraped  as  to  get  a  fresh  surface,  on  the 
principle  of  caries  of  bone.  Many  dentists  are  operating  in  this 
manner  at  the  present  time.  I  have  elsewhere  shown  simple 
absorption  and  not  caries  is  present.  Such  treatment  is  wholly 
unnecessary  and  contraindicated.  The  object  of  the  removal  of 
the  deposits  is  to  allow^  the  fibrous  tissue  of  the  peridental  mem- 
brane (after  health  is  restored)  to  tighten  about  the  root,  which 
cannot  be  accomplished  when  foreign  substances  are  present. 


324  INTERSTITIAL    GINGIVITIS. 

Pushing  instruments  must  never  be  used,  but  only  such  instru- 
ments as  have  smooth  and  round  backs,  tempered  very  liard  so 
as  to  retain  sharp  edges.  These  instruments  should  be  small, 
with  small  points  to  reach  depressions,  and  to  be  as  universal 
as  possible.  Such  an  instrument  is  to  be  found  in  the  spoon  ex- 
cavator (Fig.  101).  The  shank  can  be  bent  to  suit  the  operator. 
This  is  to  be  carried  gently  along  the  length  of  the  root  and 
passed  over  the  deposit  with  a  firm  hand,  resting  the  finger  upon 
some  other  teeth.  The  drawing  motion  is  invariably  to  be  from 
the  membrane,  and  toward  the  crown.  Attention  was  first  called 
to  the  mutilation  and  infection  of  tissues  two  decades  ago,  at 
which  time  most,  if  not  all,  instruments  for  the  removal  of  deep- 
seated  calcic  deposits  were  used  with  the  pushing  movement.^ 
The  deposits  are  scaled  off  painlessly.  The  round  blade  being 
larger  than  the  shank,  and  cutting  upon  three  edges,  half  of  the 
root  in  both  directions  can  be  circled  without  removing  the  in- 
strument. A  similar  instrument  bent  at  the  shank  in  the  oppo- 
site direction  may  be  used  on  the  other  side.  After  all  of  the 
roots  of  the  teeth  have  been  scaled,  the  spaces  are  to  be  syringed 
out  with  warm  or  hot  water.  The  gums  are  to  be  thoroughly 
saturated  inside  and  out  with  iodin.  The  gum  massage  brush  is 
to  be  used  thrice  daily  as  before.  The  patient  should  return 
twice  or  thrice  a  week  for  further  instructions.  The  contracting 
gums  will  assist  greatly  in  revealing  the  deposit.  If  deposits 
still  remain  on  the  roots  (the  appearance  of  the  gums  will  indi- 
cate its  presence)  further  use  of  the  scalers  is  indicated.  The 
delicate  instruments  and  the  accustomed  sense  of  touch  will 
reveal  the  hidden  calculus. 

With  the  precautions  already  noted,  local  anaesthesia  is 
unnecessary.  The  smooth,  round  surface  of  the  back  of  the 
instrument,  if  carefully  inserted,  will  not  produce  pain. 

If  the  gum  be  painful  to  the  touch,  or  if  the  patient  be 
nervous  and  sensitive,  application  of  iodin  may  be  used,  to- 
gether with  massage,  for  a  few  days  before  scaling  is  resorted 
to.  The  sensitiveness  will  soon  disappear,  when  the  instrument 
may  be  inserted  without  difficulty. 

'  Jour.  Am.  Med.  Assoc,  Jan.  16,  1897. 
'  International  Dental  Journal,  April,  1896. 


TREATMENT. 


325 


In  an  article  upon  -Pyoritoa  Alveolaris,'-  I  showed  the 
ditficulty  of  removing  the  deposits  upon  the  roots  of  the  teeth 
with  instruments  and  made  the  follomng  statement:  -From 
our  past  experience  in  the  treatment  of  the  disease,  the  deposits 
mnst  be  removed;  and  right  here  I  would  suggest  that  in  the 
futui^  treatment  of  this  disease  a  dissolving  fluid  that  is  not 
injurious  to  the  surrounding  tissue  should  take  the  place  of 
^  instruments,  especially  when  the  disease  is  extensive." 

I  am  pleased  to  state  at  this  time  that  Dr.  Joseph  Head  in  a 
paper,   -A    Tartar    Solvent,    Especially   Useful   in   Pvorrhoea 
Work,'-  m  which  he  demonstrated  his  experiments  upon  the 
action  of  acid  ammonium  fluorid  as  a  solvent  for  calcic  deposits 
c  aimed  to  produce  good  results  without  action  upon  the  tooth 
structure  or  soft  tissue.     This  preparation,  known  as  -Tarta- 
sol,"  can  be  obtained  at  any  of  the  dental  depots.    This  or  sim- 
ilar   drugs    and    the    method    of   application    must    eventually 
become  the  proper  treatment  for  the  satisfactory  removal  of 
deposits  upon  the  roots  of  the  teeth.    In  this  way  and  this  alone 
can  we  expect  to  obtain  a  clean,  smooth  root  surface.     A  few 
years  hence,  the  profession  will  regard  a  dentist  whose  patients 
have  pus  oozing  from  the  gums  as  a  prehistoric  relic  and  the 
patient  as  an  individual  whose  filth  provokes  the  contempt  of 
his  fellows.    In  this  day  of  antisepsis,  the  dentist  is  as  account- 
able for  pus  infection  of  his  patients  as  the  physician  or  surgeon 
There  is  no  more  excuse  for  the  dentist's  patient  being  in- 
fected than  the  surgeon's.  If  ordinary  antiseptic  precautions  are 
taken,  pus  infection  will  not  often  occur.    Prevent  inflammation 
ot  the  gum  margin  and  pus  infection  cannot  follow,  no  matter 
how  many  germs  are  in  the  mouth.    This  is  an  absolute  law  of 

bv  M-n  ""'p ''.'^T-  ^'  ^"''  ^""^ '"''''''  '''^  '^''  experiments  made 
by  Miller,  Cx.  T.  Carpenter  and  myself  on  dogs,  rabbits,  guinea 
pigs  and  man. 

The  illustrations  of  the  progress  of  interstitial  gingivitis 
teach  that  only  the  mildest  treatment  is  indicated.    Harsh  treat 
ment  on  the  inflamed  bone  or  fibrons  tissue,  either  with  instru- 
ments or  drug.,,  must  not  be  employed.    Heroic  treatment,  such 
asU,e  nubscriminate  application  of  sulphuric  and  lactic  acid  and 

s  Transactions  National  Dental  Association,  1S<)9,  p.  131. 


326  INTERSTITIAL    GINGIVITIS. 

similar  drugs  in  nearly  or  quite  full  strength,  is  not  justified  by 
the  surgical  principles  of  today.  No  surgeon  would  think  of  mak- 
ing such  an  application  to  inflamed  bone  in  other  parts  of  the 
body  unless   he  wished   necrosis   with   a   desired   sequestrum. 
Much  less  Avould  the  intelligent  operator  use  such  treatment  in  a 
transitory  structure  which  predisposed  to  destruction.     In   a 
number  of  instances  exfoliation  of  the  anterior  plate  of  the  alve- 
olar process  has  resulted  from  this  treatment,  to  say  nothing  c/. 
the  intense  pain  produced.    J.  M.  Whitney''  has  had  four  cases 
in  his  practice  in  which  serious  results  followed.    The  first  indi- 
cation is  to  remove  the  cause.     Instrumentation  should  be  re- 
sorted to  only  to  remove  tartar  and  calcic  deposits.    This  must 
be  done  in  such  a  manner  as  not  to  infect  the  deeper  inflamed 
tissue  or  carry  the  products  of  inflammation  into  healthy  tissue. 
The  treatment  of  infected  tissue  within  and  about  the  alveoli  is 
not   unlike   treatment   of   abscesses   and   ulceration   elsewhere. 
Such  drugs  as  are  used  in  abscesses  and  ulcers  in  other  tissues 
are  indicated  here  in  the  same  strength.     If  strong  drugs  be 
used  they  should  not  be  permitted  to  remain  in  the  tissue,  lest 
necrosis  of  the  alveolar  process  occur.    They  must  be  diluted  or 
removed  altogether  after  they  have  accomplished  their  purpose 
Very  serious  results  have  occurred  from  careless  use  of  drugs. 
When  abscesses  have  formed  they  should  be  opened  and  hydro- 
gen peroxid — or,  which  has  answered  my  purpose  equally  well, 
hot  water — is  all  that  is  necessary.    More  difficult  is  treatment 
of  ulceration  of  the  tissue  near  the  root  of  the  tooth.    Ordinary 
cases  will  heal  after  hot  water  or  hydrogen  peroxid  have  been 
applied.    In  some  cases  the  pus  germs  have  followed  the  inflam- 
mation along  the  course  of  the  vessels  quite  a  distance  into  the 
interstitial  tissue.    In  such  cases  they  are  difficult  to  reach.    A 
small  syringe  may  be  employed,  or  the  drug  may  be  carried  to 
the  part  on  the  end  of  a  long,  thin  orange-wood  stick.     In  all 
cases  the  drug  must  be  directly  applied  to  the  part  in  order  to 
have  beneficial  results.     Applications  of  iodin  should  be  used, 
as  already  suggested.     Iodin  carried  to  the  ulcerated  surface 
often  suffices  to  destroy  the  pus  secretion.     Ordinarily  one  or 
two  applications  is  sufficient.     Occasionally  calcic  deposits  are 


9  International  Dental  Journal,  April,  ISHD. 


TREATMENT.  327 

located  in  front  of  the  infected  surface  and  the  drug  does  not 
reach  the  part.  In  such  cases  the  deposit  must  be  removed.  If 
the  pus  does  not  cease  at  the  first,  second  or  even  third  appli- 
cation, this  is  not  because  the  drug  is  not  sufficiently  strong,  but 
because  it  does  not  reach  the  infected  part.  Continued  applica- 
tions of  iodin  externally  and  internally,  carried  well  up  between 
the  roots  of  the  tooth  and  the  alveolar  process  will,  in  time,  pro- 
duce the  desired  result.  When  pus  ceases  to  flow,  antiseptic 
treatment  must  stop.  The  iodin  and  massage  treatment  must 
then  be  pushed  until  tlie  interstitial  inflammation  has  been  re- 
duced and  the  gums  contracted  tightly  about  the  necks  of  the 
teeth. 

After  the  tissues  have  been  placed  in  a  healthy  condition, 
they  will  require  the  constant  attention  of  the  operator,  since, 
like  other  tissues  of  the  body  when  once  diseased,  favorable  con- 
ditions ^vill  cause  a  recurrence.  The  patient  must  return  to  the 
operator  frequently  so  that  he  can  advise  as  to  the  use  of 
massage. 

When  constitutional  disorders  are  the  cause  of  interstitial 
gingivitis,  local  treatment  will  not  cure  the  disease.  It  is  pos- 
sible to  deplete  the  parts  of  blood  and  reduce  the  inflammation 
to  a  minimum.  The  cause  not  having  been  removed,  the  inflam- 
mation soon  returns. 

When  the  disease  is  due  to  constitutional  causes,  tartar  de- 
posits rarely  occur;  scraping  the  roots,  therefore,  is  useless. 
Pus  germs  may  or  may  not  be  present.  The  local  iodoglycerole 
treatment,  however,  is  indicated,  but  the  constitutional  causes 
of  the  disease  must  be  considered  by  a  competent  physician. 
The  history  of  the  patient  must  be  looked  into,  a  complete  uri- 
nary examination  made  and  the  heart  pressure  taken.  The 
heart,  liver,  kidney,  bowels,  lungs  and  skin  must  be  placed  in  a 
healthy  condition ;  without  this  attention  local  results  are  impos- 
sible. Change  in  climate  and  food  frequently  benefit  the  patient. 
Loose  teeth  must  be  fastened  tightl.y  to  other  teeth;  this,  how- 
ever, is  only  temporary,  since  (as  I  have  already  mentioned)  the 
function  is  lost.  Better  results  can  be  obtained  bv  their  removal. 


328  INTERSTITIAL    GINGIVITIS. 

VACCINE    TREATMENT    OF   INTERSTITIAL    GINGIVITIS. 

In  the  treatment  of  a  disease  by  vaccine,  it  is  positively 
necessary  that  the  exact  nature  and  identity  of  the  germ  or 
germs  producing  the  disease  be  known.  It  is  also  necessary  that 
the  various  types  of  infections  as  well  as  the  pathologic  condi- 
tion in  which  the  bacteria  are  present  as  secondary  infections 
be  known. 

This  knowledge  will  prevent  the  specialist  from  using  a  vac- 
cine which  will  not  inunune  the  germs  which  produce  the  disease. 
The  technique  of  this  treatment  is  of  so  much  importance 
that  I  cannot  express  my  views  better  than  to  quote  from  an 
article,  ^'The  Principles  of  Bacterin  Therapy,"  by  Dr.  J.  Favil 
Biehn,"  "The  corresponding  bacterins  are  indicated  in  all  bac- 
terial infectious  diseases ;  but  since  the  bacterins  have  a  spe- 
cific action  only,  it  is  absolutely  essential  to  know  the  particular 
organism  or  organisms  causing  the  disease  under  treatment  and 
to  give  the  corresponding  bacterins.  Thus,  for  instance,  bacil- 
lus-coli  bacterins  are  of  value  only  in  diseases  caused  by  the 
bacillus  coli ;  they  are  practically  valueless  in  diseases  caused  by 
other  organisms.  Hence,  there  are  no  bacterins  for  such  ail- 
ments as  boils,  furuncles,  and  the  like,  for  these  conditions  are 
not  always  produced  by  the  same  organism  or  group  of  organ- 
isms. In  one  case  streptococci,  in  another  case  staphylococci 
(either  albi  or  aurei)  may  be  the  etiological  cause.  The  first 
form  will  be  benefited  only  by  the  bacterins  containing  strepto- 
cocci, while  the  second  responds  only  to  one  containing  staphylo- 
coccus albus,  etc.  However,  a  mixed  bacterin  may  be  employed, 
and  will  prove  beneficial,  provided  it  contains  the  specific  organ- 
isms responsible  for  this  particular  diseased  condition. 

"Therefore,  unless  the  exact  etiologic  cause  is  determined 
mid  the  corresponding  bacterins  are  administered,  failure  will 
surely  result.  It  is  quite  necessary,  in  case  several  pathogenic 
bacteria  are  acting  together  in  producing  a  disease,  that  the  cor- 
responding bacterins  for  all  of  them  be  utilized ;  and  further,  if 
the  infection  should  change  as  a  result  of  the  invasion  of  other 
organisms  unless  a  bacterin  for  these  organisms  is  also  used,  a 
complete  cure  may  not  be  obtained." 


10  American  Journal  of  Clinical  Medicine,  February,  page  157. 


TREATMENT.  329 

A  careful  study  of  the  researches  in  this  work  mil  show  that 
interstitial  gingivitis  is  due  to  local  and  constitutional  irritants 
and  toxins  and  not  to  infections. 

The  operator  must  not  lose  sight  of  the  fact  that  it  is  the 
inflammatory  condition  which  causes  the  absorption  of  the  alve- 
olar process,  and  the  exfoliation  of  the  teeth  and  not  the  pus 
stage.  The  pus  formation  is  the  result  and  not  the  cause  of  the 
disease. 

While  it  is  possible  that  a  vaccine  may  be  made,  of  the  pus 
germs  which  cause  the  secondary  state  of  the  disease  (pyorrhoea 
alveolaris),  which  may  possibly  render  these  germs  innocuous 
and  stop  the  flow  of  pus,  such  treatment  can,  according  to  our 
present  knowledge,  hardly  be  expected  to  reduce  the  primitive 
stage  (interstitial  gingivitis)  so  much  to  be  deplored.  It  is  barely 
possible  that  in  the  future  specific  germs  may  be  discovered 
which  may  cause  the  inflammatory  stage.  When  this  has  been 
accomplished,  a  vaccine  may  be  produced  which  will  be  a  posi- 
tive method  of  treatment.  Until  then  the  vaccine  method  of 
treatment  should  be  used  with  discretion. 


BIBLIOGRAPHY 


The  following  books  and  monographs 
of  the  author  have  been  drawn  on  largely 
for  material  in  compiling  the  present 
work. 

Books 


The  Irregularities  of  the  Teeth,  First 
Edition,  1888. 

The  Irregularities  of  the  Teeth,  Sec- 
ond Edition,  1890. 

Chart  of  Typical  Forms  of  Irregu- 
larities of  the  Teeth,   1891. 

A  Study  of  the  Degeneracy  of  the 
Jaws  of  the  Human  Race,  1892. 

The  Etiology  of  Osseous  Deformities 
of  the  Head,  Face,  Jaws,  and 
Teeth,    Third   Edition,    1894. 

Degeneracy:  Its  Signs,  Causes  and 
Results    (London),   1898. 

Interstitial  Gingivitis  or  So-called 
Pyorrhoea  Alveolaris,  1899. 

Irregularities  of  the  Teeth,  Fourth 
Edition,  1901. 

Quiz  Compend  of  Irregularities  of 
the  Teeth,  1901. 

Irregularities  of  the  Teeth,  Fifth  Edi- 
tion,  1903. 

Developmental    Pathology;    A   Study 
in   Degenerative   Evolution,    1912. 
Monographs 

Education,  Dental  Colleges  —  The 
Dental  Cosmos,   1876. 

Mercury,  Chemical  and  Physiolog- 
ical Action  of  Fillings  on  the  Sys- 
tem— The  Dental  Cosmos,  1879. 

Preparation  of  Nerve  Canals  for 
Treatment  and  Fillings — The 
Dental   Cosmos,   1880. 

Gold  Crowns — The  Dental  Cosmos, 
1880. 

Screws  for  Artificial  Crowns — The 
Dental  Cosmos,  1881. 

Treatment  and  Filling  of  Approx- 
imal    Cavities — The    Dental    Cos- 


mos,  1881. 
The  Regulation  of  Teeth  by   Direct 

Pressure — The     Dental     Cosmos, 

1881. 
Dental    Regulating   Apparatus — The 

Dental   Cosmos,   1885. 
Spreading     the     Dental     Arch — The 

Dental    Cosmos,   1886. 
Regulating   Individual    Teeth — The 

Dental  Cosmos,  1886. 
Pyorrhoea     Alveolaris,     ist     Paper — 

The  Dental  Cosmos,  1886. 


12.  The  Etiology  of  Irregularities  of  the 

Teeth— The  Dental  Cosmos,  1888. 

13.  Arrest  of  Development  of  the  Maxil- 

lary Bones,  due  to  Race  Crossing, 
Climate,  Soil  and  Food — The 
Dental   Cosmos,   1888. 

14.  Development  of  the  Inferior  Maxil- 

la by  Exercise  and  Asymmetry 
of  the  Lateral  Halves  of  the 
Maxillary  Bones — The  Dental 
Cosmos,  1888. 

15.  Asvmmetrv   of   the    Maxillary   Bones 

—  The  Dental  Cosmos,  1888. 

16.  The    Alveolar    Process — The   Dental 

Cosmos,  1888. 

17.  The     Origin     and     Development    of 

the  V  and  Saddle  Arches  and 
Kindred  Irregularities  of  the 
Teeth— The  Dental  Cosmos,  1889. 

18.  The  Above  Concluded — The  Dental 

Cosmos,  1889. 

19.  Classification   of   Typical    Irregular- 

ities of  the  Maxillae  and  Teeth — 
The  Dental   Cosmos,   1889. 

20.  Statistics   of   Constitutional   and   De- 

velopmental Irregularities  of  the 
Jaws  and  Teeth  of  Normal,  Idiot- 
ic, Deaf  and  Dumb,  Blind  and 
Insane  Persons — The  Dental  Cos- 
mos, 1889. 

21.  Fallacies  of  Some  of  the  Old  Theo- 

ries of  Irregularities  of  the  Teeth 
with  Some  Remarks  of  Diagnosis 
and  Treatment — The  Dental  Cos- 
mos, 1890. 

22.  The  Teeth  and  Jaws  of   a  Party  of 

Cave  and  Cliff  Dwellers — The 
Dental  Cosmos,  1890. 

23.  The  Differentiation  of  Anterior  Pro- 

trusions of  the  Upper  Maxilla 
and  Teeth,  International  Medical 
Congress,  Berlin — The  Dental 
Cosmos,  1890. 

24.  Mouth-Breathing    not    the    Cause    of 

Contracted  Jaws  and  High  Vaults 
— The   Dental   Cosmos,    1891. 

25.  Management    of    Dental    Societies — 

The  Dental  Cosmos,  1891. 

26.  Studies    of    Criminals — The   Alienist 

and  Neurologist,  1891. 

27.  Scientific    Investigation    of    the    Cra- 

nium and  Jaws — The  Dental  Cos- 
mos,   1891. 

28.  Evidence  of  Somatic  Origin   of  Ine- 

briety— Journal  of  Inebriety,  1891. 


BIBLIOGKAPHY. 


331 


29.  A    Study   of   the    Degeneracy   of   the 

Jaws  of  the  Human  Race — The 
Dental  Cosmos,   1892. 

30.  Empj-ema    of    the    Antrum — Journal 

of  the  American  Medical  Asso- 
ciation,  1893. 

31.  The    Vault    in    its    Relation    to    the 

Jaw  and  Nose — The  Dental  Prac- 
titioner  and  Advertiser,   1894. 

32.  Stigmata  of  Degeneracy  in  the  Aris- 

tocracy and  Regicides — Journal  of 
the  American  Medical  Associa- 
tion,  1894. 

33.  The     Degenerate     Ear — Journal     of 

the  American  Medical  Associa- 
tion, 1895. 

34.  Pyorrhoea    Alveolaris,    2nd    Paper — 

International  Dental  Journal, 
1896;    The  Dental   Cosmos,   1896. 

35.  Dental  and  Facial  Evidence  of  Con- 

stitutional Defect — The  Interna- 
tional Dental  Journal,  1896. 

36.  H.      H.      Holmes — Journal     of     the 

American  Medical  Association, 
1896. 

37.  Pyorrhoea    Alveolaris,    3rd    Paper — 

Journal  of  the  American  Medical 
Association,  1896. 

38.  Degeneracy  of  the  Teeth   and  Jaws 

— Journal  of  the  American  Medi- 
cal Association,  1896. 

39.  Oral    Hygiene — International    Medi- 

cal Congress,  Moscoiv,  1897. 

40.  Autointoxication   in   its   Medical    and 

Surgical  Relations  to  the  Jaws 
and  Teeth — Journal  of  the  Amer- 
ican Medical  Association,   1897. 

41.  Pyorrhoea    Alveolaris    in    Me-curial 

and  Lead  Poisoning  and  Scurvy, 
4th  Paper — Journal  of  the  Ameri- 
can Medical  Association,  1898. 

42.  Degeneracy    in    its    Relation    to    De- 

formities of  the  Jaws  and  Irregu- 
larities of  the  Teeth— r//^  Chica- 
go Dental  Revieiv,  1898. 
1.3.  A  Study  of  the  Stigmata  of  Degen- 
eracy among  the  American  Crimi- 
nal Youth — Journal  of  the  Ameri- 
can Medical  Association,  1898. 

44-  Irregularities   of  the   Dental   Arch — 

1898. 

45-  A    Study   of   the    Deformities    of   the 

Jaws  among  the  Degenerate 
Classes  of  Europe — The  Interna- 
tional Dental  Journal,   1898. 

46.  Inheritance    of    Circumcision    Effects 

— Medicine,    1898. 

47.  What  Became  of  the  Dauphin  Louis 

XVII?  A  Studv  in  Dental  Juris- 
prudence— Medicine,   1899. 

48.  Interstitial    Gingivitis    due    to    Auto- 

intoxication —  The  International 
Dental   Journal,    1900. 


49.  Traitement    de    la    Pyorrhie    Alveo- 

dentaire — XIII  International  Med- 
ical Congress  Proceedings,  Paris, 
1900. 

50.  The   Intervention  of  Therapeusis   in 

Anomalies  of  Position  and  Direc- 
tion of  the  Teeth — XIII  Interna- 
tional Medical  Congress  Proceed- 
ings, Paris,  1900. 

51.  Limitations    in    Dental     Education — 

Journal  of  the  American  Medical 
Association,  1900. 

52.  Interstitial    Gingivitis   from   Indiges- 

tion Autointoxication — Journal  of 
the  American  Medical  Associa- 
tion, 1900. 

53.  Interstitial    Gingivitis    as    a    Promi- 

nent Obvious  Early  Sympton  of 
Autointoxication  and  Drug  Poi- 
soning— Chicago  Medical  Society 
Proceedings,    1901. 

54.  Peridental         Abscess  —  Proceedings 

Xe^v  York  State  Dental  Society, 
1901.  The  Chicago  Dental  Re- 
i>ieiv,  1 90 1. 

55.  Oral      Manifestations      and      Allied 

States — Journal  of  the  American 
Medical  Association,  1901. 

56.  Degeneracy  and  Political  Assassina- 

tion— Medicine,   1901. 

57.  The    Higher    Plane    of    Dentistry — 

Revue  de  Stomatologic,  Paris 
1902. 

58.  Juvenile     Female    Delinquents — The 

Alienist    and    Xeurologist,     1901- 
2-3- 
59-  The    Stigmata    of    Degeneracy — The 
Medical     Examiner     and    Practi- 
tioner,  1902. 

60.  Deformities  of  the  Bones  of  the  Nose 

and  Face — The  Laryngoscope, 
1902. 

61.  Evolution    of    the    Pulp — Journal    of 

the  American  Medical  Associa- 
tion, 1902. 

62.  Why  Dentists  do  not  Read — The  In- 

ternational Dental  Journal,  1903. 

63.  How    Far    do    Stomatologic    Indica- 

tions Warrant  Constitutional 
Treatment? — The  International 
Dental  Journal,  1903. 

64.  Syphilitic      Interstitial      Gingivitis — 

The  International  Dental  Journal 
1903. 

65.  Gum     Massage— r//^"     International 

Dental  Journal,  1903. 

66.  The    V^asomotor   System  of  the   Pulp 

— Journal  of  the  American  Medi- 
cal Association,  1903. 

67.  Recognition   of  the  D.   D.   S.   Degree 

by  the  American  Medical  Asso- 
ciation— Dental   Journals,    1903. 

68.  What     the     Physician     or     Surgeon 

should  know  of  Dentistry — Iltt- 
nois  Medical  Bulletin,  1903. 


332 


INTERSTITIAL    GINGIVITIS. 


69.  Pathogeny  of  Osteomalacia  or  Senile 

Atrophy — Journal  of  the  Ameri- 
can Medical  Association,  1904. 

70.  Constitutional   Causes  of  Tooth   De- 

cay— The  Dental  Digest,  1903. 

71.  Interstitial     Gingivitis    or    So-called 

Pyorrhoea  Alveolaris — The  Dent- 
al Summary,  1903. 

72.  Buccal  Expressions  of  Constitutional 

States — Medicine,       1903.  The 

Dental  Digest,  1903. 

73.  Endarteritis  Obliterans  and  Arterio- 

sclerosis of  the  Alveolar  Process 
—  The  Dental  Digest,  1903. 

74.  Pathology    of    Root    Absorption    and 

Alveolar  Abscess — The  Dental 
Digest,  1904. 

75.  The  Relations  of  the  Nose  and  Geni- 

talia— Medicine,  1904. 

76.  Pulp    Degeneration — Journal    of   the 

American  Medical  Association, 
1904. 

77.  Criminal  Responsibility   and   Degen- 

eracy— British  Medical  Associa- 
tion, Section  on  Psychological 
Medicine,  1904. 

78.  Anatomic     Changes     in     the     Head, 

Face,  Jaws  and  Teeth  in  the 
Evolution  of  Man — Fourth  Inter- 
national Dental  Congress,  St. 
Louis,   Mo.,   1904. 

79.  Constitutional   Causes   of  Tooth   De- 

cay, Erosion,  Abrasion  and  Dis- 
coloration— Fourth  International 
Dental  Congress,  St.  Louis,  Mo., 
1904. 

80.  Etiology     of     Cleft     Palate — Fourth 

International  Dental  Congress,  St. 
Louis,  Mo.,  1904. 

81.  Scorbutus    or    Interstitial    Gingivitis 

— Medical  Nen.vs,  1904. 

82.  Negro     Ethnology     and     Sociology — 

Illinois  Medical  Bulletin,   1905. 

83.  Gonorrhoeal        Ulcero-Membraneous 

Stomatitis  —  The  International 
Dental  Journal,  1905. 

84.  Evolution    of    the    Central    Nervous 

System — The  Dental  Digest,  1905. 

85.  Study  of  the  Pithecanthropus  Erectus 

or  Ape-Man — The  International 
Dental  Journal,  1905. 

86.  Advance    and    Retrogressive    Evolu- 

tion— The  Dental  Digest,   1905. 

87.  Underlying  Factors  of  Development- 

al Pathology  or  Suppressive  Evo- 
lution— The   Dental  Digest,   1905. 

88.  Laws      Governing      Eugenesis :        A 

Thirty-five  Years  Study  of  Devel- 
opmental Pathology — The  Dental 
Era,   1905. 

89.  Developmental  Pathology  and  Tooth 

Decay — The  Dental  Cosmos,  1905. 

90.  Errors     in     Dental     Education — The 

Dental   Cosmos,   1906. 


91.  Interstitial  Gingivitis  due  to  Autoin- 

toxication: Etiology — The  Dental 
Digest,  1906. 

92.  Interstitial  Gingivitis  due  to  Autoin- 

toxication as  Indicated  by  the 
Urine  and  Blood  Pressure  Diag- 
nosis— The  Dental  Digest,   1906. 

93.  Therapeusis    and    Treatment    of    In- 

terstitial Gingivitis  due  to  Auto- 
intoxication— The  Dental  Digest, 
1906. 

94.  Acid   Autointoxication    and   Systemic 

Disease  the  Cause  of  Erosion  and 
Abrasion — Proceedings  of  the 
Neiu  York  State  Dental  Society, 
1907. 

95.  Alcohol   in  its   Relation  to  Degener- 

acy— Journal  of  the  American 
Medical  Association,  1907. 

96.  Acid    Intoxication    or    Acidosis:      A 

Factor  in  Disease — Neiv  York 
Medical  Record,   1907. 

97.  Stomatology   in   its   Medical    Aspects 

— Extrait  du  Bulletin  of  the  Inter- 
national Association  of  Stomatol- 
ogy,  Bruges,    1908. 

98.  Swan     Songs     and    Degeneration    of 

American  Dental  Colleges — The 
Dental  Cosmos,  1908. 

99.  The     Care     of     the     Teeth — Illinois 

Medical  Bulletin,  1908. 

100.  Etiology  of  Face,  Nose,  Jaw  and 
Tooth  Deformities — Journal  of 
the  American  Medical  Associa- 
tion, 1909. 

loi.  Bone  Pathology  and  Tooth  Move- 
ment— Journal  of  the  American 
Medical  Association,   1909. 

102.  Acidosis,    Indicanuria,    Internal    and 

External  Secretions:  the  Effects 
upon  the  Alveolar  Process  and 
Teeth — The  Dental  Cosmos,  1908. 

103.  Sense    and    Nonsense    as    taught    in 

American  Dental  Schools — The 
Dental   Cosmos,  1909. 

104.  Treatment   of    Interstitial    Gingivitis 

— The  Dental  Cosmos,  1909. 

105.  Progress  of  Stomatology  in  Europe — 

The  Dental  Cosmos,  1909. 

106.  Hard    Teeth    and    Soft    Teeth— The 

Dental   Cosmos,   1909. 

107.  Progress  of  Stomatology  in  Hungary 

— American  Journal  of  Clinical 
Medicine,   1909. 

108.  Local      Manifestations     of     Systemic 

Diseases — XFI  International  Med- 
ical  Congress,  Budapest,   1909. 

109.  How  Shall  the  Stomatologist  be  Edu- 

cated ? — International  Association 
of  Stomatology,  Budapest,   1909. 

110.  Scope    of    Developmental    Pathology 

—  The  Alienist  and  Neurologist, 
Feb.   1910. 

111.  Rip  Van  Winkles  in  American  Dent- 

al College  Faculties — The  Dental 
Cosmos,   1910. 


BIBLIOGRAPHY. 


333 


112.  The  Scope  of  Developmental  Pathol- 
ogy in  its  Relation  to  Oral  Mani- 
festations— International  Ameri- 
can Congress  of  Medicine  and 
Hygiene,  1910. 

1x3.  Oral  Hygiene  in  American  Dental 
Schools: — The  Dental  Cosmos, 
1910. 

114.  The  Acidemic  Condition — The  Med- 

ical Standard,  1910. 

115.  lodin    as    an    Astringent,    Antiseptic, 

Disinfectant  and  Germicide  in  the 
Treatment  of  Mouth  Diseases — 
Journal  American  Medical  Asso- 
ciation,  1910. 

n6.  How  Shall  the  Stomatologist  be  Ed- 
ucated?— Journal  American  Med- 
ical Association,  1910. 

117.  Care  of  the  Mouths  of  School  Chil- 
dren— The  Dental  Summary, 
1910. 

ti8.  The  Quality  of  Service  Rendered — 
The  Dental  Summary,   1910. 

119.  What  are  Dentists  as  a  Profession 
doing  to  Advance  their  Specialty? 
— The  Dental  Summary,   1910. 


120.  Treatment    to    Alleviate    the    Conta- 

gions, Infections  and  Local  Dis- 
eases of  School  Children — The 
Dietetic  and  Hygienic  Gazette, 
1910. 

121.  Developmental    Pathology:    A   Study 

in  Degenerative  Evolution — Pro- 
ceedings of  the  First  District 
Dental  Society  of  New  York, 
1910. 

122.  The     Future     of     Dentistry — Sunday 

Editorial  in  The  Chicago  Tribune. 
1911. 

123.  Some    Bacterial     and     Non-Bacterial 

Diseases — Dental  Summary,  June 
1912. 

124.  The   Relation   of   Rheumatic   Arthri- 

tis to  Pvorrhoea  Alveolaris — 
Clinical  Medicine,  November, 
1912. 

125.  Degeneracies,   the  Result  of  Alcohol 

and  other  Narcotics — Read  before 
Society  for  the  Study  of  Alcohol 
and  Other  Narcotics,  at  Washing- 
ton, D.  C,  Dec.  11-12,  1912. 

126.  Interstitial  Gingivitis  and  Pyorrhoea 

Alveolaris  — Journal  American 
Medical  Association,   191 3. 


INDEX  OF  AUTHORS 


Page 

Adami     123 

Alexander,    H.    C.    B 173 

Allbright     3 

Allen,    Harrison    22 

Andrews,   R.   R 88 

Arkovy     4 

Atkinson     4 

Barker     272 

Barrett   314 

Bauman     239 

Beaumont     203 

Bernard,    Claude    203 

Bichat     201 

Biehn,   J.    Favil 328 

Billings,    Frank    298 

Black 5,  42,   50,   52,   53,   56,   57 

Boak,  G.   D 213 

Boedecker    314 

Bondurant    207 

Bonwill     2 

Bouchard,   H.   H 184,   239 

Braconnot    239 

Bremer,  L 228 

Brown    2 

Brown-Sequard    271 

Brubaker,    A.    B 90 

Bui  lard    227 

Calve,  Marshall    2 

Carpenter 104,  108,  109,  283,  289 

Carter    239 

Cartwright,  Hamilton   4 

Chittenden,  Prof.  Russell    H 242 

Christian    202 

Clowes    3 

Coles,  Oakley   4 

Collins,  J 86 

Congdon,   Ernst   90 

Coplans,  Mayer    219,  220 

Croftan,   Alfred   C 70 

Cruveillier    207 

Davis,    David   J 308 

Dickinson,   Howship   78 

Dray,  Arthur  R 21 

Ebner,  Von   62 

Eisenhart    277 

Enderlein     76 

Essig,   C.  J 3 

Evans,  W.  A 106 

Farrar,  J.   N 4 

Fauchard,    H.    A 2 

Fitzgerald,  John 10,  90,  295,  296 

Flower,  Alsop  E 126 

Foster    14 

Gallippe 4,   16,   104 

Geddings,   H.   D 75 

Gilmer    305 


Page 

Gmeiin     239 

Goadby,  K.  B 220,  302 

Gubler     239 

Hafner    215 

Hammarsten    87 

Hartzell,    T.    B 306 

Hassal    239 

Head,  Joseph   325 

Hektoen 156,  265 

Herschell    296 

Hertwig    62 

Herzog    108 

Hodgen    233 

Hogben    173 

Howell    177 

Hunter 298,  301 

Ingersoll,    L.    C 4 

Izklai,  Joseph   4 

Jacobson     75 

Jaffe    239 

Joirac,  M 2 

Jourdain     2 

Jurgensen     194 

Kaecker,    L 2 

Kaufmann 66,   275,   276 

Kiernan    271 

Kirk 124,    184,  206 

Klebs    122 

Koch    16 

Kolliker 35,   37,   62,  279 

Krabler    194 

Kuh,   Sidney   273 

Kuttner    282 

Libman,  E 309 

Macauley    242 

Magitot 2,  8,   57,  61,  64,  206 

Mailhol    14 

Malassez     4 

Malenfant    79 

Marinesco    271 

Mendel    228 

Metchnikoff 236,  239,  258 

Miller 9,   102,  103,  104,   105,  286 

Mills,  G.  A 3 

Minot 38,    58,    62 

Moorehead,   Frederick    299 

Morgan,  de  36 

Meyer     233 

Mummery    2i 

Murchison     202 

Murrell     228 

Nasse    271 

Nencki     239 

Niles,    N.    S 3 

O'Neill,    Eugene    F 21 

Osier    300 


INDEX  OF  AUTHORS.  335 

„     ,                                                                   f*2g^  Page 

Parker     213     Sirletti     3 

Patterson,  J.  D 4,  6,  9,  103    Stadeler    239 

Pedley,  Newland 7,  8    Starr,    A.   R 5 

Pierce,  C.  N 9,   16,  90,  91,  206    Stevenson    yg 

P'tres    273    Stewart    297 

Planer 238,  239    Suckdorf    237 

Prout 203    Sudduth,  W.  X 6,  8,  9,   105    279 

Purdy    257    Sutton,  Bland   8 

Quain    13    Talbot,  E.  S 5,  10,  11,  12,  104,  182 

Ravvls,  A    0 4,  233  186,   191,   197,   324 

Recklinghausen,  von 277    Thoma    122 

•^eese     4^    Thompson    202 

Reeves    90    Tiedemann    239 

Rehwinkle    3    Tomes   36,  314 

Rennert    232    Tuke    203 

Rhein,  M.  L 9,  90,  104,  105,  206,  314   Turck   272 

Riggs,  John  T 2    Vaillard ..273 

Robin 57,    60,   61,   64,   206,   239    Valentine    271 

Roger,   G.  H 239    Vaughn    195 

Rokitansky     282    Vignas    237 

Rosenovv,   Edward   E 309    Virchow    282 

Rush    228    Waldeyer 62 

Salisbury,  J.   H 79,  91,  93    Walker   4,  21 

Salkowsky    239    Waller   .'271 

Salter    52    Ward,    Charles    22 

Sayre,  Charles  E 126    Wesener    91,  92 

Scheele 87,  89    Whitnev,  J.  M '326 

Scheff 2    Whitslar,   W.    H 316 

Scheheotskey  78    Wood,  James    227 

Schieff    239    Wright,    A.    E 219 

Schmidt    78    Zawadsky    76 

Selmi     235    Ziegler 32,  212,  276 

Senator    239    Ziemssen    194 

Shambaugh,  G.  E 299    Zilz     300 


INDEX  OF  SUBJECTS 


Abscess,   Alveolar,  290. 

Alveolar,  Production  of,  290. 

Formation,   Description  of,   117. 

Pericemental,    297. 

Peridental,   123. 
Abscesses,   Location  of,   287. 

Treatment  of,  326. 
Acid  Autointoxication    and   Mouth   Acidity, 
250. 

Excess  of  System,  Disposal  of.  Through 
Salivary   Glands,   254. 

States,    198. 
Alcohol,   Constitutional  Effects  of,  226. 

Effect  of,  on  Alveolar  Process,  224. 
Altitude,     High,     Effect     of,     on     Alveolar 
process,   216. 

High,  Effect  of  on  Teeth  and  Gums,  215. 
Alveolar  Abscess,   290. 

Production   of,   290. 
Alveolar-Process,    abnormal,    30. 

Absorption  of,  25,  28,   121,   189,  205,  271, 

Absorption    of,    and    Calcic    Deposits    on 

Roots   of   Teeth,    275. 
Absorption     of,     Caused      by     Excessive 

Brushing  of  Teeth,  189. 
Absorption  of,  in  Asthma,  205. 
Absorption    of,    in   Bright's    Disease,    205. 
Action  of  Poisons  on,  223. 
And   High   Blood   Pressure,   208. 
And   Lessened   Blood   Alkalinity,   256. 
And  Poisons   in   Circulation,   209. 
Arrested    Development    of,    30. 
As  End  Organ,  70,   118,  121,  236. 
As   Transitory   Structure,   236. 
Atrophy  of,  197. 
Blood    Vessels   of,    177. 
Changes  in  Function  of,   184. 
Effect  of  Acid  States  on,  199. 
Effect  of  Constitutional    Disturbances  on, 

207. 
Effect  of  Diabetes  on,  207. 
Effect  of  Exanthemata  on,   205. 
Effect  of  High  Altitude  on,  216. 
Effect  of  Interstitial   Inflammation  on,   in 

Dog's  Tooth,   137. 
Effect    of    Nutritional     Disturbances    on, 

233- 

Effect  of  Picking  Teeth  on,   190. 

Effect  of  Pregnancy  on,  200. 

Effect  of  Tobacco,  Alcohol,  Tea,  Coffee, 
Drugs  and  Poisons  on,  224. 

Effect  of  Toxins  on,  223. 

Endarteritis  Obliterans  and  Arterioscle- 
rosis of  Vessels  in,  266. 

Exfoliation   of  Anterior   Plate    of,    326. 

Growth  of,  24. 


Alveolar-Process,   Hypertrophy  of,   30,   33. 
In   Phosphorus    Poisoning,    121. 
In   Tuberculous    Monkey,   Absorption   of, 

155- 
inflammations  of,    113. 
Injury  to,  by  Bridgework,  188. 
Injury  to,   by   Gold  Crowns,    188. 
Nerve   Supply  in,   123. 
Obliteration  of  Arterioles   in,   266. 
Osteomalacia  of,  197,  200,  277. 
Overlapping  Fillings  Cause  of  Injury  to, 

189. 
Structure   of,    25. 
Toxemia  and,  199. 
Transitory   Nature   of,   69,   96. 
Under  the  Microscope,  35. 
Wasting    of,     and    Facial     Hemiatrophy, 
208. 
Antimony    as    Cause    of    Interstitial    Gin- 
givitis,   173. 
Arsenic    as    Cause    of    Interstitial     Gingi- 
vitis, 173. 
Arteries,  Changes  in  Walls  of,  in  Disease, 
261. 
Irritations  of  Walls  of,  263. 
Arteriosclerosis    and    Nerve    End    Oblitera- 
tion, Degeneration,  261. 
Of  Alveolar  Blood  Vessels,  266. 
Asthma,    Absorption    of    Alveolar    Process 

in,  205. 
Atmospheric    Pressure    and   Bleeding   From 

Gums,   215. 
Atrophy  from  Disuse,  237. 
Autoinfections,    236. 
Autointoxication,   236,   244. 
Factors   in,   201. 
In  Interstitial   Gingivitis,   235. 
In   Neurotics  and  Degenerates,  242. 
Indicanuria  as  Source  of,  258. 
Urinary   Signs    of,   247. 
Bacillus    Coli    Communis    as    Inhabitant   of 

Mouth,   296. 
Bacteria   Infesting  Mouth,   296. 
Bacterial    Experiments   in    Interstitial    Gin- 
givitis,   104. 
Infection   of   Man,    236. 
Thrombosis     in     Peridental     Membrane, 
162. 
Bacteriology  of  Interstitial   Gingivitis,    104. 
Bile,    Composition   of,    75. 
Blood,  Alkalinity  Effect  of  Lessened,  256. 
Analysis    of,    73. 

From  Portal   Vein,  Toxicity  of,   240. 
Pressure,    High,    and    Alveolar    Process, 

210. 
Pressure,    High,    and    Gingivitis,    208. 


INDEX  OF  SUBJECTS. 


337 


Blood,    Vessels   of   Gums   Alveolar   Process 

and  Pericemental  Membrane,  177. 
Body  Equilibrium,   Maintenance  of,  on  Re- 
stricted Diet,  242. 
Heat,    196. 

Refrigeration  of,  212. 
Temperature    and    Climate,    211. 
Bone    Absorption,    66. 

Absorption   in    Inflammation,    120,    124. 
Building  and  Absorption,   64. 
Brass-Worker's    Ague    as    Cause    of    Inter- 
stitial Gingivitis,   172. 
Bridgework,   Injurious  Effect  of,   on   Aveo- 

lar  Process,  188. 
Bright's    Disease,    Absorption    of    Aveolar 

Process   in,   205. 
Bromides  as   Cause  of  Interstitial  Gingivi- 
tis,   173. 
Cachexia,    198. 

Calcic   Deposit:      See    also   Tartar. 
Calcic  Deposits  on    Teeth:  See  also  Serum- 

al   Deposits. 
Calcic  Deposits  on  Teeth.   10,   83,  280. 

Deposits,  Removal  of,  323. 
Calcification,  Causes  of,  282. 
Calcospherites,    50,    162. 
Catarrh  Coexistent  with  Pyorrhoea  Alveo- 

laris,    103. 
Cementoblasts  in  Dog's  Tooth,  140. 
Children,   Neurotic  and   Degenerate,   Erup- 
tion of  Teeth  in,  182. 
Climate  and  Scurvy,  218. 
Coca,  Abuse  of,  229. 
Cocain,  Effect  of,  on  Gums,  230. 

Effects  of   Use   of,  229. 
Coffee,   Nervous   Symptoms   of,  227. 
Criminals,  Chest  Formation  of,  205. 

Tuberculosis   in,   205. 
Crowns    and   Bands,    320. 
Degeneracy   of   Tissues,    100. 
Degenerates,    Autointoxication   in,   242. 
Dental  Arches,  Irregular,   102. 
Pulp:     See  also  Tooth. 
Pulp,    n8. 

Shelf,   Development  of,    58. 
Shelf,    Embryology   of,    62. 
Dentistry  as  Cause  of  Interstitial   Gingivi- 
tis,   182. 
Modern,  Diseases  Caused  by,   319. 
Dentures,  A.rtificial,   320. 
Digestive-Apparatus,     Evolution     of,     237, 
240. 
In  Differing  Types,  241. 
Diabetes,    Effect    of,    on    Alveolar    Process, 

207. 
Diabetic  Patients,   Uranalysis  in,  251. 
Drug  Poisons,   Nervous  Effects  of,  231. 
Drugs,  Effect  of,  on  Alveolar  Process,  224. 
Nervous   Symptoms    Due   to   Use  of,   228, 

Poisonous   Effects,   First   Noted   in   Gums, 
230,   234. 
Dyphodontia,    12. 
Emotions   and   Their'  Physical   Effects,   201. 

And    Trophoneuroses,    271. 

Violent,  and  Nutrition,  204. 


Enamel  Organ,  59. 
Endarteritis,  Causes  of,  263. 

Definition    of,    263. 

Obliterans    and     Nerve    End    Degenera- 
tion,   261. 

Obliterans    in    Alveolar    Blood    Vessels, 
266. 
Environment   in    Interstitial    Gingivitis,    95. 
Epithelial  Debris,  60. 
Evolution     of     Digestive     Apparatus,     237, 

240. 
Exanthemata,      Effect      of,      on      x'\lveolar 

Process,    205. 
Face,   Evolution  of,   113. 
Facial      Hemiatrophy      and      Wasting      of 

Alveolus,   208. 
Faeces,  Salts  in,  76. 
Fever,   Cause  of,   195. 
Fever,  Definition  of,  194. 
Fevers,   Trophic   Changes  After,    206. 
Gum   Margin,   Irritation   of,    182. 

Massage,   314,   316. 

Wash,    316. 
Gums,    Bleeding    From    as    Effect    of    At- 
mospheric   Pressure,    215. 

Bloodvessels    of,    177. 

Effect  of  High  Altitude  on,  215. 

Effect  of  Poisons  on,   199,  230. 

First   Structure    to   Indicate   Certain    Sys- 
tematic Defects,  250. 

Inflammation   of,  in   Scurv\",  209,   220. 

Irritation  of,  66. 

Signs   of   Drug   and   Metal   Poisoning   in, 
114. 

Structure  of,  40. 

Ulceration    of,    271. 
Gingival   Glands,   52. 

Organs,   52,  90. 
Gingivitis,  Philology  of,  14. 
Gold  Crowns  and  Destruction  of  Alveolar 

Process,    188. 
Gout,   Deposits  in  Tissues  in,  79. 
Halisteresis,   Definition  of,  276. 
Heat,   Difference  Between  that  of  Sun   and 

Shade  Heat,  213. 
Heredity    in    Interstitial    Gingivitis,    95,    96. 
Horses,   Cause   of  "Cribbing"  in,   126. 
Hygiene   in    the   Tropics,    213. 
Hypophysis  Cerebi,  Disorders  of,  and  Body 

Changes,    34. 
Indican,   Effects  of  Administration   of,   239. 

In   Organism,   Effect  of,   258. 
Indicanuria     and     Neurasthenia,     Relation- 
ship of,  257. 

As    Source   of  Autointoxication,    258. 
Infection,   Susceptibility  to,   and  Low  Tem- 
perature, 212. 
Inflammation,    Active,    Illustration    of,    114. 

And   Bone   Absorption,    120. 

Behavior  of  Blood  in,   115,   120. 

Leucocytes  in,   115. 

Nervous    System   in,   122. 

Production  and  Course  of,   114. 

Without    Gingivitis,     112. 
lodoglycerole,    318. 
Insane,  Disturbances  of  Teeth  in,  207. 


338 


INDEX  OF  SUBJECTS. 


Instruments  to  be   Used  in  Removing  Cal- 
cic Deposits,  323. 
Intermarriage,  Effect  of,  on  Teeth,   97. 
Interstitial,   Foster's   Definition  of,   14. 

Quain's   Definition   of,    13. 
Interstitial-Gingivitis      and      Constitutional 
Diseases,   236. 

And  Higli  Blood  Pressure,  208. 
And  Inorganic  Salts,   73. 

And    Irregular   Arches,    102. 

And    Uric  Acid,   87. 

And    Pericementitis,    176. 

And  Poisons  in   Circulation,   209. 

Animal    Research   on,    125. 

Antimony  as  Cause  of,   173. 

Arsenic  as  Cause  of,   173. 

Autointoxication    in,    235. 

Bacteriologic  Researches   in,    104. 

Brass-worker's  Ague  as  Cause  of,   172. 

Bromides   as   Cause  of,    173. 

Contagiousness   of,   6. 

Caused    by   Regulation    of   Teeth,    190. 

Choice    of,    in    Preference    to    Pyorrhoea 
Alveolaris,    13,    15. 

Condition  of  Urine  in,  247. 

Constitutional   Causes  of,  8,  84,   194,   327. 

Definition   of,   112. 

Degenerate  Tissues   in,   100. 

Differential  Diagnosis  of,  221. 

In  Defective   Children,  103. 

In   Dogs,    126. 

In   Dogs,  Technique  of  Examination   for, 
131. 

In  Human,  Autopsy  Findings,  156. 

In  Man  From   Drugs,   170. 

In  Pregnant  Women,   8,   176. 

In  Soldiers  in  the  Tropics,  213. 

Infectivity  of,    17. 

Influence   of  Climate  in,  211. 

lodin  Treatment  of,  317,  322. 

Irregular  Teeth    and,    6. 

Laboratory  Experiments  in,    105. 

Local  and  Constitutional  Causes  of,   104, 

175- 
Local  Causes  of,  5,  84,  104,  112,  175,  182. 
Mercurial,  in  Dogs,   150. 
Method    of    Extension    of,    to    Aleovolar 

Process,    276. 
Drug  and   NIetal   Poisons  in  Etiologv  of, 

84. 
Etiology  of,   84. 
Frequency  of,  in  Animals,   126. 
Heredity  and  Environment  in,  95. 
History  of,    i. 
In    Animals,    7,    8. 
In   Children,   82. 

Modern  Dentistry  as  Cause  of,   182,   186. 
Nature  of  Structures   Involved  in,    112. 
Pathognomonic   Symptoms   of,    312. 
Persons  with  Predisposition  to,   124. 
Point  of   Commencement  of,    56. 
Predisposition    to,    100. 
Pregnancy    and,    8,    176. 
Recovery   From,   286. 
In    the   Human,    Researches    on,    156. 
Scorbutus  in,   85. 


Interstitial-Ciingivitis,   Scurvy  in,  218. 
Symptoms  of,  7. 
Syphilis   in,   Etiology   of,   8,   9. 
Tartar  as  Cause  of,  112. 
Theories  of,  84. 
Tooth    Eruption    and,    182. 
Treatment  of,  310. 
Trophic  Disturbances  in,   86. 
Uncleanliness    as    Cause    of,    186. 
Vaccine  Treatment  of,    328. 
With    Intestinal    Fermentation,    244. 
Intestinal    Putrefaction    and   Toxins    in    the 

Blood,   239. 
Jaw,    Arrested    Development    of,    95. 

Effect   of   Phosphorus    Poisoning  on,    120. 
Excessive    Development   of,    95. 
Variation  in    Dogs,   127. 
Jaws,   changes   in,   238. 
Deformities    of,    242. 
Evolution  of,  19,  113. 

Irregular  in   Neurotics   and   Degenerates, 
96. 
Kidney    Disease,    Absorption    of    Alveolar 

Process   in,   205. 
Laboratory      Experiments      in      Interstitial 

Gingivitis,    105. 
Lymph,   Salts  in,  76. 

Mallet,   Excessive   Use  of   as   Cause   of  In- 
flammation   of    Peridental    Membrane, 
187. 
Maxillary    Necrosis,    271. 
Metabolic   Disturbances   and   Their   Effects, 
196. 

Mental    States,    Physical    Effects   of,    201. 
Mouth  Acidity   and   Acid   Autointoxication, 
250. 

Infection   and   Glandular  Affections,   297. 

Toxins    Generated   in,    199. 
Mucous-Membrane,   Glands,   in,    50,   57. 

Irritation    of,    66. 

Of  Mouth,  38. 

Of  Mouth,  Blood  Vessels  and  Nerves  of, 
40. 

Under   Microscope,    53. 
Nerve      End      Degeneration,      Endarteritis, 
and    Arteriosclerosis,    261. 

Exhaustion     in     Parents,     Effect     of,     on 
Child's   Teeth,   97,    loi. 

Supply   in   Alveolar   Process,    123. 
Nerves,  Effects  of  Toxins  on,  273. 
Nervous   System   in   Inflammation,    122. 
Neurasthenia     and     Indicanuria,     Relation- 
ship  of,   257. 
Neurotics,   Autointoxication  in,  242. 
Nutrition,    Causes  of  Arrest  of,   223. 

Disturbances    of.    Effect   of,    on    Alveolar 
Process,  223. 

Modification  of,  by  Emotions,  204. 
Opium,   Nerve   Effects  of,  228. 
Osteoclasts,    279. 
Osteomalacia,    197. 

Of  Alveolar  Process,   197,  200,  277. 

Varieties    of,    276. 
Pancreatic    Juice,    Composition    of,    76. 
Paretic  Patients,   Urine  in,  252. 


INDEX  OF  SUBJECTS. 


339 


Pericemental     Membrane,     Bloood     Vessels 

of,  177. 
Pericementitis,    175. 

And    Interstitial    Gingivitis,    176. 

Artificial   Production  of,   176. 

Author's   Researches   on,    176,    178. 

Causes  of,  176. 

Due  to  Syphilis,  176. 

Effect  of  on  Surrounding  Tissues,   176. 

In    Human,    Research    on,    175. 

Phagedenic,  53. 
Peridental   Abscess,  123. 
Peridental-Membrane,  27,  42,  45. 

Bacterial    Thrombosis    in,    162. 

Blood   Vessels   in,   49. 

Cells    in,    65. 

Condition  of,  in  Pyorrhoea,  289. 

Cross    Sections   of,    57. 
Peridental-Membrane,      Degeneration      of, 
From  Drugs,  172. 

Effect  of  Interstitial   Inflamm.ation  on,   in 
Dog's   Tooth,    137. 

Excessive    Use    of    Mallet    Cause    of    In- 
flammation   of,    187. 

Glands  in,   50. 

Hard    Bodies    in,    50. 

Infection    of,     96. 

Irritation    of,    66. 
Periostitis,  Suppurative,   162. 
Periosteum,   42. 

Perspiration,  Inorganic  Salts  in,  76. 
Phosphorus    Poisoning,    Effect   of,   on   Jaws, 

120. 
Poison,  Scant  Elimination  of,  by  Skin,  242. 
Poisons,    Action    of,    on    Alveolar    Process, 
223. 

Classification   of,   223. 

Effect  of,  on  Gums,  230. 

Elimination  of,  243. 
Polyphyodontia,    12. 

Potassium    Bromide    as    Cause    of    Intersti- 
tial  Gingivitis,   173. 
Pregnancy,   Elimination  of  Poisons  in,   243. 

Urinary  Acidity  in,  244. 
Purin    bodies,    88. 
Pyorrhoea-alveolaris,   96,   124,  285. 

And    Irregular   Arches,    102. 

Bacteria    in,    106. 

Catarrh  Coexistent  Vi^ith,   103. 

Constitutional   Effects  of,  295. 

Description  of,  285. 

Development  of,  285. 

In  Animals,  106,  129,   131. 

In   Dog's  Teeth,  Technique  of  Examina- 
tion for,   131. 

In    the    Human,    106. 

In    Troops,    220. 
Rachitis,  Association  of.  With   Scurvy,  218. 
Saliva,  Composition  of,  78. 
Salivary    Calculi,    Composition    of,    79. 

Concretions,   98. 

Glands,    Effect   of  Tobacco   on,    225. 
Salivation    in    Scurvy,   221. 
Scalers,  Description  of  Author's,  321. 
Scurvy   and   Armies,   218. 

And  Climate,  218. 


Scurvy,    and    Food,  219. 

And  Inflammation  of  Gums,  209. 

And    Interstitial    Gingivitis,    236. 

Causes   of,   218. 

Differential   Diagnosis  of,  220. 

In  Interstitial  Gingivitis,  218. 

In    Institutions,   221. 

Rachitis  with,  218. 

Salivation    in,    221. 

Symptoms  of,  220. 
Sedentary  Habits,  Effects  of,  89. 
Serumal    Deposits:      See    also    Calcic    De- 
posits. 
Serumal    Deposits    on    Teeth,    Analysis    of, 

.79- 
Skin,  Scant  Elimination  of  Poisons  by,  242. 
Status    Epilepticus,    201. 
Submaxillary    Gland,    185. 
Submucous      Membrane,     Proliferation      of 

Epithelial    Cells   in,    58. 
Syphilis    and    Interstitial    Gingivitis,   236. 
Tabes    Dorsalis,    Urine    in,    252. 
Tartar:     See   also  Calcic    Deposit. 
Tartar,    184,    320. 

And    Malnutrition,    185. 
Salivary,  Formation  of,   184. 
Solvent    For,    325. 
Tea-tasters,    Nervous    Symptoms    in,    226. 
Teeth:      See    also    Tooth. 
Teeth,   Calcic   Deposits  on,  280,   323. 

Cavities    in,    and    Overlapping    Fillings, 
Cause   of   Injury   to   Alveolar   Process, 
189. 
Change   of  Position  of,   31. 
Effect  of  Acid   States  on,   199. 
Effect  of  High  Altitude  on,  215. 
Eruption  of,  64,  319. 
Eruption    of,    and    Interstitial    Gingivitis, 

182. 
Eruption  of,  in   Neurotic  and  Degenerate 

Children,   182. 
Evolution  of,  113. 

Examination  of,   for   Uric  Acid,   90. 
Excessive    Brushing    of,    and    Bone    Ab- 
sorption,   189. 
Decay  of,   196. 
Deformities  of,  242. 

Degeneration  of,  Due  to  Evolution,  238. 
Devitalization  of  Pulps  of,   188. 
Disturbances  of,  in  the  Insane,  207. 
Falling     Out     of,     and     Trophoneuroses, 

271. 
Description   of,   285. 
Individual,  Correction  of,  320. 
In   Inmates    of   Institutions,   221. 
Irregular,    186. 
Loosening  of,   271. 
Method  of  Eruption   of,    64. 
Milk,   Formation  of  Papilla;  for,   58. 
Of   Defective    Children,    103. 
Picking   of,    Efl^ect   of,   on   Alveolar    Pro- 
cess, 190. 
Proper  Way  of  Brushing,  313. 
Result  of  Wedging  Apart  of,  193. 
Regulation    of,    and    Interstitial    Gingivi- 
tis, 190. 


340 


INDEX  OF  SUBJECTS. 


Teeth,   Sliape  of  Crowns  of,  27,  29. 

Sockets    of,    26. 
Temperature,    Sudden   Changes   in,    Consti- 
tutional   Effects   of,    215. 

Effect  of  Lowering  of,  211. 
Tissue    Degeneration    in    Internal    Organs, 

196. 
Tobacco,   Constitutional   Effects   of,   224. 

Effect  of,  on  Alveolar  Process,  224. 

Effect  of,  on   Salivary  Glands,  225. 

Mental   Effects   of,   225. 
Tooth:     See   also  Teeth. 
Tooth  Brush,  Best  Kind  to  Use, 

Destruction,    Role    of    Friction 

Teeth   and    Foreign   Bodies    in,   250. 

Germs,    Development    of,    in    Mammals, 
58. 

Pulp,   Death   of,   196. 
Toxins,     Effect    of,     on    Alveolar    Process, 

523. 
Toxins  Producing  Trophic  Changes,  223. 
Transitory-Structures,   19,  24. 

Arrested  Development  of,  113. 
Trophic   Changes    Caused    by   Toxins,    223. 
Trophoneuroses   and  Emotions,  271. 


313- 
of 


Lips, 


Tropics,    Hygiene    in,    213. 
Tuberculosis     and     Interstitial     Gingivitis, 
236. 

Effect  of,   on   Alveolar   Process,   207. 

In   Criminals,  205. 
Ulceration,   Location   of,   289. 
Uric-Acid    and   Interstitial    Gingivitis,    87. 

Crystals    on    Teeth,    Inaccuracy    of    Dry 
Distillation    Test    for,    92. 

Laboratory    Examination    of    Teeth    for, 
90. 

Poisoning,    89. 

Tests  for,  on  Teeth,  90,  91. 
Urinary-Acidity  in  Pregnancy,  244. 

In   Senility,  255. 

In  various  diseases,   254. 
Urine,  Examination  of,  in  Interstitial   Gin- 
givitis, 247 

In    Diabetic   Patients,    251. 

Inorganic    Salts    in,   77. 

In   Paretic  Patients,   252. 

In  Tabetic  Patients,  252. 

Report  of  394  Examinations,  247. 

Toxins    in,    201. 
Wallerian    Degeneration,   271. 


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